The Commerical Determinants of Health

America blames its health crisis on the individual.

Nason Maani

You are eating too much junk food, drinking too much, gambling away the spare savings you have and not exercising.

What do you expect?

But what about the commercial determinants of health?

The powerful corporations that shape our society, bend our science, and inform our culture?

Public health experts only recently are turning their attention to how powerful commercial forces shape us more than we shape ourselves.

Many of them have come together to put out a new book – The Commercial Determinants of Health edited by Nason Maani, Mark Petticrew and Sandro Galea (Oxford University Press, 2022.)

Nason Maani is a lecturer in global health inequality at the University of Edinburgh.

The book has 34 chapters with titles including How Do Commercial Determinants Shape Upstream Drivers of Health? The Role of Corporations in Influencing Culture and Industry Influence on Science: What Is Happening and What Can Be Done. 

You don’t have to go and have lunch at KFC or McDonald’s. You can cook for yourself and eat healthy on a limited budget. And you can exercise regularly. What part of this is personal choice compared to what you present in your book as corporate driven determinants of health? Whose fault is it?

“I don’t think it’s necessarily a question of fault,” Maani told Corporate Crime Reporter in an interview last month. “It’s more a question of bearing witness to powerful forces that shape our environments and choices.” 

“It’s well established that about 80 percent of health outcomes are determined by factors outside of healthcare. It’s about the quality of housing you live in, the air you breathe, the food you have access to – these kinds of wider determinants outside yourself.” 

“And you can see that everywhere. You can see that the life expectancy gaps in different neighborhoods of the same city. You take a city like Boston and go to a more deprived part of Boston like Roxbury, life expectancy is in the high 50s or early 60s. You go to a wealthy suburb like Brookline, it’ll be in the mid 80s.”

“And that’s not because of individual choices. That’s because of the difference in these other factors. And those are the social determinants of health. A lot of those in turn aren’t just shaped by government action, they’re shaped by commercial interests, really powerful entities.” 

“It’s not just the physical environment. They also shape our social norms. Coca-Cola spends billions a year on marketing, on creating social norms around when it’s appropriate to consume their products and how often and who identifies with them.”

“It’s wrong that science doesn’t pay more attention to these forces. It’s simply unscientific to not consider these impacts.”

You write – “The world around us is shaped by forces beyond government policy.” How in a democracy can that be true?

“These commercial forces are kind of like the elephant in the room. Think about any policy, from local government to national government that relates to health. There are often opportunities for corporations to input, either in providing expert advice, or evidence in opposition to certain policies.” 

“When there have been moves to enact soda taxes for example, you see that. Or, in the past, when there were efforts to restrict the availability of cigarettes. You had lobbyists, industry funded epidemiologists. You had front groups.” 

“These forces clearly exist and they do exert influence. And to some degree, understandably so. Their job is to seek profits and protect revenues. They take a portion of their current revenue to protect future revenue. The problem arises when that comes into conflict with the health of the population.”

“Understanding that conflict and understanding how to predict those actions and intervene is important. Ignoring that conflict of interest or assuming that it doesn’t have a significant influence is problematic, particularly in a country like the U.S. where corporate funding can have significant impacts on elections.” 

“So to suggest that that doesn’t then shape government decisions is probably a bit fanciful.”

But you say bluntly – “the world around us is shaped by forces beyond government policy.” 

Government did act to prohibit smoking on network television. The government mandated auto companies to put airbags in automobiles. And those came from popular movements to overcome corporate power. So it’s not inherently so that “the world around us is shaped by forces beyond government policy.”

“Many of these policies are a consequence of compromise and delay. In some cases, they are very incomplete. Take the example of social media. A large portion of people’s lives is now on social media platforms. And these are not public spaces. These are for profit companies that host platforms and they are advertising platforms. Those have a significant impact on policy debates, on misinformation, on public opinion, on our lives.” 

If it’s not going to be democratic pressure through government to control corporate power, what’s it going to be?

“Definitely, democratic pressure is part of it. But the important thing to remember is that a lot of these corporations are multinational. That becomes a real problem in controlling their impact. It isn’t necessarily something that can be done at the national level.” 

“Some colleagues and myself have done some work on cross border alcohol marketing. 

When it happens online and on social media, it’s not like billboards. It’s not like physical advertising or TV or print advertising. It’s permeating internationally.” 

“Then you need more global accountability mechanisms or ways global instruments can assess the global footprint of companies.” 

One of the chapters in your book addresses corporate influence over science. A couple of years ago we published an article on the West Virginia School of Public Health taking money from Coca-Cola. 

Is that kind of direct donation to try and shape a university school of public health an outlier?

“I don’t think it’s an outlier and I don’t think it’s restricted to public health. Scholars have shown that there is a long history of corporate efforts to influence science. It goes right back to lead, asbestos, tobacco. We think of it as primarily something the tobacco industry did, but that’s in part because they got caught. But it’s now part of the corporate playbook. Where there is emerging science that is harmful to the bottom line, there is then a drive to create doubt about that science and to seek alternative explanations.”

“You mentioned the Coca Cola example. I myself did research on Coca Cola and its links to the Center for Disease Control. We looked at emails revealed under the Freedom of Information Act that showed that former Coca Cola executives have made close connections with staff at CDC in the obesity department and we’re using those connections to influence policy and to seed Coca-Cola funded research at the CDC. It was often about the lack of physical activity being the primary driver of obesity.” 

“So they were funding a lot of physical activity research and then using that research to dispute sugar sweetened beverages links to obesity.”

“You can totally see why it makes sense from the perspective of Coca Cola. But unfortunately, it has major significant impacts on health. In the research we did, we showed that  through the CDC, Coca-Cola was able to lobby the WHO directly. That’s pretty profound.  That’s really an example of a corporate actor shaping health policy or trying to shape policy all the way to the global level.”

When it comes to raising children, the forces of corporate power often overwhelm parental control. How do you protect your children from the corporatization of society?

“I had never thought of it that way. The reason I changed careers and got into public health and ended up doing what I am doing is because I felt I wasn’t doing work that was consistent with my values. When I was working in clinical trials, after a couple of years I realized that these conflicts of interest were quite powerful. I didn’t doubt the quality of the science that was being done, but I could see the ways these companies were choosing which products to take to market. They were clearly focusing on their competitors and how much money they could make rather than on what would most benefit people and societies.”

“I struggled with that. My dad was a social worker. We never had that much money growing up. And he came home and you could tell he believed in what he was doing. And when he took me to his work, I got a strong sense that he lived a life aligned with these values.” 

“The reason I changed my career was that I wanted to be a good example to my three young sons. I decided to try and counteract some of those negative influences on society.” 

“I’ve tried to do work that aligns with my values and show my sons that they can do that as well. It’s less about protecting them from a corporatized world. It’s more about saying to them – you do have some agency.

You can choose what you dedicate your life to doing.”

We have an election coming up and corporate power should be front and center. Instead social issues predominate. Those issues are turning the country to the right. Why is it that corporate issues are not front and center?

“In part, it’s because much harm is perfectly legal and is considered a normal part of our economic and social lives. When I went to the US, I was struck by the inequality.”

“It’s in part because of the success of corporations.” 

“David Foster Wallace gives a talk about two young fish swimming past an older fish. And the older fish says – how is the water, guys? And he swims on past. Then one young fish turns to the other young fish and says – What the hell is water?”

“Maybe that’s part of the reason corporate power isn’t a more potent political issue. There is an aspect of it that it is just the water that we swim in. It’s sort of invisible.”

[See Interview with Nason Maani, 36 Corporate Crime Reporter 46, November 28, 2022, print editoin only.]

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