Written by:
Nason Maani
Mark Petticrew
One of the key challenges the Transforming Evidence community has identified for future research is around who is producing what kinds of knowledge - how types of diverse knowledge influence and frame decision-maker’s debates. How can we bring knowledge together across disciplines and what knowledge infrastructure might we need to do this? Can we help develop new frameworks of social determinants of health, that include consideration of commercial influences?
How can we bring knowledge together across disciplines and what knowledge infrastructure might we need to do this?
What is health?
We seem innately predisposed to equate health with healthcare: individuals tend to think of doctors, nurses and treatments and policy-makers of statistics on healthcare and biomedical research. But health is much more than that.
To borrow a metaphor, if the forces that determine our health were players in a football team, then healthcare is the goalkeeper. It is the last resort to turn to, when everything else has failed. A good goalkeeper is a great asset to have when things go wrong, but they can’t save every shot, and can’t bear the primary responsibility for winning the game.
The outfield players that generate health are the conditions around us, things like the health of one’s mother when she was pregnant, the quality of the air we breathed as a toddler, the school we went to, parks we played in, social norms we were exposed to, the safety nets we could rely on, and the opportunities we could reach for.
These social determinants of health, to a large degree generate health at the population level, and explain why we see such differences in life expectancy by postcode, even when these postcodes are served by the same healthcare system. Attempts to grapple with this include “health in all policies” approaches, or go further, as in the case of New Zealand’s “well-being budget”. While such concepts are promising, not all stakeholders are best served, or accounted for, by them.
The influence of commercial determinants of health
Commercial determinants of health are, broadly speaking, those activities of the private sector that affect the health of populations. These can be direct, such as the marketing of unhealthy products, or more distal, like industry lobbying against emissions regulations, or duty increases, donating to political campaigns, funding dubious research and generating doubt around product harms.
Until recently, except for the tobacco industry, the commercial determinants have remained largely absent from our conceptual frameworks of the social determinants of health as we found in a recent review. To go back to the football analogy, they are like a key player whose influence we have failed to take into account or meaningfully address.
This is especially challenging as a single large industry sector can have a profound, intersectional impact on our sociocultural and physical environments. They can affect everything from the consumption patterns of a particular product, to the social norms surrounding when and how much of it we use, to the tax and regulatory frameworks surrounding it, the science regarding its harms and benefits, how policy-makers view the problem and its causes, and the framing of possible solutions.
Particularly at a time when public-private partnerships are seen as a cost-effective way to tackle urgent problems, it is imperative we have the evidence base and theoretical frameworks to guide us around the direct and distal pitfalls of partnering with such entities.
Particularly at a time when public-private partnerships are seen as a cost-effective way to tackle urgent problems, it is imperative we have the evidence base and theoretical frameworks to guide us around the direct and distal pitfalls of partnering with such entities.
The challenges for research
Research on this subject is growing but faces a number of challenges, which we outlined in a recent commentary. Agreement is needed on a common, inclusive definition of the commercial determinants of health. Data access is a challenge, but innovative approaches such as the use of novel data sources have helped to provide evidence on issues such as the misrepresentation of product risks, and less savoury attempts to influence policy.
A lot of existing research is generated in industry-specific silos, with a focus on a product category, such as tobacco or alcohol. This runs the risk of missing the cumulative effects of such actors in areas such as deregulation or the framing of policy options, with downstream consequences for population health and health equity. We need more empirical work of an interdisciplinary nature, but also, new fora that might allow cross-disciplinary communication and collaboration on these issues.
What can the Transforming Evidence community do?
This area could benefit from the development of new frameworks of social determinants of health, that include consideration of commercial influences. Multidisciplinary appraisals of gaps in our understanding that can aid the prioritization of new research could then emerge from such frameworks. Much work needs to be done to engage policy-makers and the public around the evidence that does exist on the activities of commercial actors that influence health directly and distally, particularly as we turn increasingly to public private partnerships, not least the context of COVID-19.
In other words, we need new ways to work across sectors, better frameworks around which to situate existing research and to identify knowledge gaps, and to aid in the development of policy-relevant solutions. In all these ways, the commercial determinants of health represent exactly the type of research challenge that the Transforming Evidence community exists to overcome.
Nason Maani is a Harkness Fellow in Healthcare Policy and Practice at Boston University School of Public Health.
Mark Petticrew is Professor of Public Health Evaluation at the London School of Hygiene and Tropical Medicine
Featured photo by Sean Benesh on Unsplash.