Business and Health: An Insidious Mix

Abstract

Current threats to global health include the escalating burden of the climate emergency and the noncommunicable conditions driven by fossil fuels, deforestation, tobacco and processed foods. These threats translate into premature death, widespread disability and profound loss of productivity. Internationally, the powerful impacts of the social determinants on health are widely recognised yet the impact of commercial determinants of health are often less visible but exert an enormous and lasting impact. Recognising this influence should be a target for not just public health policies but purchasing policies, health information and professional education (Gilmore et al. 2023; Freudenberg et al. 2021).

The commercial determinants of health should be key a focus for nurses working in clinical practice, education, research and policy. To date, many health interventions in the nursing literature focus on the individual but it is important to recognise the complex interactions of factors driving optimal health outcomes. Increasingly, there is recognition of the importance of considering social and ecological factors contributing to health outcomes. Such an approach demonstrates the complex interplay of individual, interpersonal, organisational, community and societal factors that influence health outcomes (de Lacy-Vawdon and Livingstone 2020).

Kickbusch and colleagues have defined commercial determinants of health as strategic activities employed by the private sector to promote products and health behaviours that are detrimental to the health of an individual or society (Kickbusch, Allen, and Franz 2016). This is not to say that all private or commercial interests are solely driven by a profit motive but there are stark examples of where we need to stop and take stock. Globalisation of trade, corporate structures, regulatory and policy systems, marketing and geopolitical power brokers all contribute to the commercial determinants of health at the macro level (de Lacy-Vawdon and Livingstone 2020).

Frequently, commercial determinants of health have focussed on noncommunicable diseases but they can be widely applied to a range of healthcare issues. During the COVID 19 pandemic, these factors were demonstrated to influence vaccine availability and health system responses (Freeman et al. 2023).

In spite of the decades long research into the deleterious impacts of tobacco use on health and successive efforts to control exposure to nicotine (Flor et al. 2021), the rise of vaping internationally is a huge concern (Jonas 2022). Concerted and targeted advertising that focussed on teens and young adults has heralded a new era in nicotine uptake and hence research. The increase in tobacco controls in high income countries has shifted the focus of companies to low- and middle-income countries and markets with less regulatory barriers and high numbers of young people to target (AlDukhail and Agaku 2024; Nguenha et al. 2024). Moreover, company ownership changes and investment practices make it much more challenging to monitor adequately the activities and marketing of tobacco companies (van den Berg, de Jeu, and Boytchev 2024) as they have acquired vaping and pharmaceutical companies.

Misinformation and disinformation associated with nutritional information and dietary advice are commonplace (Diekman, Ryan, and Oliver 2023). Decades of deliberately confusing information and marketing strategies about diet has left many individuals, particularly with lower health literacy, confused and often suffering the outcomes from false and misleading ‘health’ messages (Southwell et al. 2023). In 2023, the World Health Organisation issued a guideline recommending against the use of non-sugar sweeteners to control body weight or reduce the risk of noncommunicable diseases. This report, based on the findings of a systematic review, identified no benefit from sugar substitution and, conversely, potentially deleterious effects such as the increased risk of Type 2 diabetes (World Health Organisation 2023).

As rates of obesity and related noncommunicable diseases rise, it is increasingly a global concern to protect children from unhealthy food marketing. Globally, efforts need to be re-doubled to foster dietary quality and lifelong healthy eating habits (Kelly et al. 2023). Globally, commercial marketing is associated with lower levels of breastfeeding (Zhu et al. 2023) as well as a range of unhealthy eating practices later in life.

Over 55% of the world's population live in urban areas, and this is expected to increase to 68% by 2050 (World Health Organisation 2024). The impact of urbanisation is a contentious issue. In some instances, it can improve health through access to services, but these benefits are not universally distributed across society. There are food deserts in many urban areas where people do not have access to fresh fruits and vegetables (Janatabadi, Newing, and Ermagun 2024). Moreover, strategic positioning of fast food outlets often targets the most vulnerable (Block, Scribner, and DeSalvo 2004).

Australians are the world's biggest per capita gamblers and advertising permeates the media especially during the broadcast of sporting events. The lives of many individuals and families are ruined by gambling (Marko et al. 2023). Much of the community see this as a problem that can and should be addressed, yet governments are reticent to control advertising and marketing due to powerful commercial lobbying from the gambling sector and the beneficiaries of their advertising revenue (Gordon 2024).

Addressing the commercial determinants of health is complex and requires engagement from governments, civil society, the private sector, regulatory and international bodies. Across all health professions, there is an increased focus on health equity and the forces that potentiate disparities. For many clinicians and researchers, the thought of addressing the commercial determinants of health can seem to be insurmountable. It is critical that we understand the drivers and contributors of inequitable outcomes if we are to be able to act effectively for the individuals, families and communities we serve (Lacy-Nichols, Jones, and Buse 2023). Firstly, we have to be aware of the often aggressive tactics and marketing strategies even when masked as corporate social responsibility measures that are used by many commercial interests. We need to be able to incorporate these factors in health literacy interventions.

We need to advocate for civil society organisations, including our professional organisations, to advocate for policies that uphold public health and hold those to account for harmful practices. At the government level, activities need to be cross-jurisdictional including trade, taxation and urban planning, to ensure activities are not at cross purposes. At the societal level, we need to focus on regulation, monitoring and enforcement as many commercial interests are highly skilled at identifying loopholes. Education and public health campaigns are important, but they are only one part of the solution in the face of the onslaught of commercial interests pushing products that detract from the health of the community. We also need to have a comprehensive view of how consumers are engaged, and where gender is used detrimentally (McCarthy et al. 2023).

Health professionals need to foster research undertaken to address the impacts of commercial practices and identify the need for targeted interventions. Importantly, we need to foster the ethical reporting of research where there is data transparency, particularly regarding commercial involvement in research and its reporting. Sadly, there are many examples where data have been used unscrupulously for commercial advantage at the cost of health and well-being (Rao and Wang 2017). Health professionals are highly trusted and must use this privilege wisely when endorsing or advertising particular products.

Not all commercial interests are bad, but we need to foster an ecosystem where commercial interests support, rather than hinder, health and well-being. Everyday, clinicians and particularly nurses, are faced by the outcomes of commercial determinants of health. Standing up for and addressing these drivers can no longer be solely the domain of public health practitioners and legislators. It requires all of us to step up, ensure the reliability and validity of data and make certain that the information presented is accessible and accurate. Importantly, it compels us to engage in the political process and ensure we advocate for health equity and social justice. This will never be possible until we meaningfully address the commercial determinants of health.

The authors declare no conflicts of interest.