Framing Commercial Determinants of Health: An Assessment of Potential for Guiding More Effective Responses to the Public Health Crises of the 21st Century.

Policy Points The commercial determinants of health (CDH) framework can inform public health policy, practice, and research in ways that contribute to overcoming the world's most serious public health challenges. By documenting the pathways by which commercial actors shape health, the CDH framework can provide a unifying focus for collective action to prevent and ameliorate global health crises. To realize these opportunities, CDH proponents need to find synergies in the multiple emerging streams of research, practice, and advocacy and create a body of scientific evidence, methodologies, and ideas that can inform a public health practice for the 21st century.

Commercial determinants of health: future directions.

This paper is about the future role of the commercial sector in global health and health equity. The discussion is not about the overthrow of capitalism nor a full-throated embrace of corporate partnerships. No single solution can eradicate the harms from the commercial determinants of health-the business models, practices, and products of market actors that damage health equity and human and planetary health and wellbeing. But evidence shows that progressive economic models, international frameworks, government regulation, compliance mechanisms for commercial entities, regenerative business types and models that incorporate health, social, and environmental goals, and strategic civil society mobilisation together offer possibilities of systemic, transformative change, reduce those harms arising from commercial forces, and foster human and planetary wellbeing. In our view, the most basic public health question is not whether the world has the resources or will to take such actions, but whether humanity can survive if society fails to make this effort.

Defining and conceptualising the commercial determinants of health.

Although commercial entities can contribute positively to health and society there is growing evidence that the products and practices of some commercial actors-notably the largest transnational corporations-are responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity; these problems are increasingly referred to as the commercial determinants of health. The climate emergency, the non-communicable disease epidemic, and that just four industry sectors (ie, tobacco, ultra-processed food, fossil fuel, and alcohol) already account for at least a third of global deaths illustrate the scale and huge economic cost of the problem. This paper, the first in a Series on the commercial determinants of health, explains how the shift towards market fundamentalism and increasingly powerful transnational corporations has created a pathological system in which commercial actors are increasingly enabled to cause harm and externalise the costs of doing so. Consequently, as harms to human and planetary health increase, commercial sector wealth and power increase, whereas the countervailing forces having to meet these costs (notably individuals, governments, and civil society organisations) become correspondingly impoverished and disempowered or captured by commercial interests. This power imbalance leads to policy inertia; although many policy solutions are available, they are not being implemented. Health harms are escalating, leaving health-care systems increasingly unable to cope. Governments can and must act to improve, rather than continue to threaten, the wellbeing of future generations, development, and economic growth.

Integrating Public Health Research and Teaching With Social Justice Activism: Lessons From 80 Years of Practice.

In this commentary, we reflect on the lessons we have learned from our successes and failures in aligning the roles of scholars and activists. Our hope is to provide insights that can guide public health students, faculty, practitioners, and activists seeking to chart their professional, political, and personal futures in today's polarized and catastrophe-burdened world. Several experiences motivate us to write this commentary now. In the last few years, inspired in part by the new activism against systemic racism sparked by the murder of George Floyd and others, growing climate emergencies, the COVID pandemic, anti-immigrant politics, increasing anti-Asian acts of violence, gun bloodshed, attacks on the right to reproductive and sexual health, resurgence of interest in worker organizing, and the ongoing quest for lesbian, gay, bisexual, transgender, and intersex (LGBTQI+) rights, we are impressed by the number of young people engaged in activism to defend and expand their rights and show that another world is possible.

How do childcare and pregnancy affect the academic success of college students?

OBJECTIVE: We examined socioeconomic, academic, and health-related factors associated with respondent reports that childcare interfered with academics. PARTICIPANTS: 176 undergraduate student parents. METHODS: We administered a cross-sectional survey to a representative sample of students at a public university in New York City. Using a sub-set of those who reported being parents/guardians (n = 176), we conducted bivariate analyses to assess factors associated with childcare problems interfering with school. RESULTS: About 30% of the sample reported that childcare interfered with school somewhat/moderately/a lot in the last year. Compared to those with no/little perceived interference, they were significantly more likely to need mental health treatment (30% vs. 13%; p < 0.01), worry that they would run out of food sometimes/often (32% vs. 16%; p < 0.01), and experience housing problems (26% vs. 9%; p < 0.01). CONCLUSIONS: Offering mental healthcare and services addressing food and housing insecurity can help college students to navigate challenges inherent to being a student parent.

Integrating Social, Political and Commercial Determinants of Health Frameworks to Advance Public Health in the twenty-first Century.

Existing frameworks seek to elucidate the social, political, and commercial determinants of health in order to inform practice, policy, and research that can improve health and reduce health inequities. Each approach has widened the scope of public health practice and research and identified new partners and targets for intervention. But as the public health crises of the past decade have shown, these frameworks have not yet yielded insights that have enabled the public health profession and movement to prevent or overcome dominant threats to global health and health equity. This report explores the value of an integrated framework that combines insights from previous scholarship and practice using the social, political, and commercial determinants of health. It proposes the questions such an integration would need to answer and suggests processes and tasks that could lead to the creation of a blended framework.

Assessing the health impacts of transnational corporations: a case study of Carlton and United Breweries in Australia.

BACKGROUND: The practices of transnational corporations (TNCs) affect population health through unhealthy products, shaping social determinants of health, or influencing the regulatory structures governing their activities. There has been limited research on community exposures to TNC policies and practices. The aim of this paper was to adapt existing Health Impact Assessment methods that were previously used for both a fast food and an extractives industry corporation in order to assess Carlton and United Breweries (CUB) operations within Australia. CUB is an Australian alcohol company owned by a large transnational corporation Asahi Group Holdings. Data identifying potential impacts were sourced through document analysis, including corporate literature; media analysis, and 12 semi-structured interviews. The data were mapped against a corporate health impact assessment framework which included CUB's political and business practices; products and marketing; workforce, social, environmental and economic conditions; and consumers' adverse health impacts. We also conducted an ecological study for estimating alcohol attributable fractions and burdens of death due to congestive heart disease, diabetes mellitus, stroke, breast cancer, bowel cancer and injury in Australia. Beer attributable fractions and deaths and CUB's share were also estimated. RESULTS: We found both positive and adverse findings of the corporation's operations across all domains. CUB engage in a range of business practices which benefit the community, including sustainability goals and corporate philanthropy, but also negative aspects including from taxation arrangements, marketing practices, and political donations and lobbying which are enabled by a neoliberal regulatory environment. We found adverse health impacts including from fetal alcohol spectrum disorder and violence and aggression which disproportionately affect Indigenous and other disadvantaged populations. CONCLUSION: Our research indicates that studying a TNC in a rapidly changing global financialised capitalist economy in a world which is increasingly being managed by TNCs poses methodological and conceptual challenges. It highlights the need and opportunity for future research. The different methods revealed sufficient information to recognise that strong regulatory frameworks are needed to help to avoid or to mediate negative health impacts.

Responding to Food Industry Initiatives to Be "Part of the Solution" Comment on "'Part of the Solution': Food Corporation Strategies for Regulatory Capture and Legitimacy".

In response to growing concerns about chronic diseases, food insecurity, low-wage food labor, and global warming, the food industry has developed new strategies to respond to its critics and pursue its business and political goals. As Lacy-Nicholas and Williams described in a recent review, the food industry has expanded its repertoire from opposition to critics to appeasement, co-option, and partnerships.1 Defining themselves as "part of the solution," the food industry seeks to disarm its opponents, shift policy debates to favor its interests, or delay decisions that jeopardize its profits or power. This commentary explores how health professionals, can respond to this changing repertoire. Lessons from previous campaigns to control harmful industry practices,2 suggest that no single strategy will counter changing food industry efforts to achieve its goals. Thus, advocates must consider a portfolio of approaches that can be deployed in response to changing circumstances, industry tactics, and threats to health.

Food insecurity associated with educational disruptions during the COVID-19 pandemic for college students and the role of anxiety and depression.

Objective: To test the association between food insecurity and educational disruptions from the COVID-19 pandemic and the role of anxiety or depression in mediating this association. Participants: Representative sample of 2,282 City University of New York students. Methods: Using an April 2020 online survey, we estimated adjusted prevalence ratios (aPR) for educational outcomes based on food insecurity status, adjusting for age, sex, race/ethnicity, and degree level with weighted Poisson regressions with robust standard errors. Results: Prevalence of decreased ability to do schoolwork was greater in those with moderate (aPR = 1.12, 95% CIs 1.02, 1.23) and high (aPR = 1.18, 95% CIs 1.08, 1.2) levels of food insecurity compared to food-secure students. Results were similar for dropping/withdrawing from classes and expecting delays or uncertainty around graduation. Anxiety and depression mediated the relationship between food insecurity and educational outcomes. Conclusion: Findings emphasize the urgency of expanded food assistance and mental health services for college students.

Use of environmental scan to assess density, content, and variation of predatory food and beverage marketing in New York City.

To explore the presence of predatory food and beverage marketing in different neighborhoods in New York City (NYC), this study describes the methodology of an outdoor environmental scan of the physical environment. The study was conducted in four NYC neighborhoods over a three-week period, in which pairs of trained researchers canvassed designated neighborhoods to document the presence of food and beverage marketing using photographs taken on digital smart phone devices. Commercial areas in the vicinity of NYC Public Schools and NYC Housing Authority campuses located in four neighborhoods with the highest and lowest nutrition related health indicators were studied: South Bronx, Pelham Throggs Neck, Upper West Side, Chelsea/Greenwich Village. Advertisements were coded against 50+ indicators to quantify pertinent variables including the frequency and content of food and beverages advertised and all forms of predatory marketing observed. Comparisons of prevalence and content of food and beverage advertisements and predatory marketing were made across neighborhoods with the highest and lowest health indicators, using chi-squared analysis, and a significance level of p < 0.05. This article demonstrates a disproportionate presence of predatory marketing in low income NYC neighborhoods with negative health outcomes compared to wealthier neighborhoods. Further, this paper demonstrates the benefits and limitations of using an environmental scan methodology to assess predatory food and beverage marketing in a large urban area such as NYC.

The Mediating Effect of E-Cigarette Harm Perception in the Relationship between E-Cigarette Advertising Exposure and E-Cigarette Use.

Exposure to e-cigarette advertising is associated with e-cigarette use among young people. This study examined the mediating effect of e-cigarette harm perception on the above relationship. Cross-sectional survey data were collected from 2112 college students in New York City in 2017-2018. The analytic sample comprised 2078 participants (58.6% females) who provided completed data. Structural equal modeling was performed to examine if e-cigarette harm perception mediated the relationship between e-cigarette advertising exposure (via TV, radio, large signs, print media, and online) and ever e-cigarette use and susceptibility to e-cigarette use. About 17.1% of participants reported ever e-cigarette use. Of never users, 17.5% were susceptible to e-cigarette use. E-cigarette advertising exposure was mainly through online sources (31.5%). Most participants (59.4%) perceived e-cigarettes as equally or more harmful than cigarettes. Advertising exposure showed different effects on e-cigarette harm perception depending on the source of the advertising exposure, but perceiving e-cigarettes as less harmful than cigarettes was consistently associated with e-cigarette use and susceptibility. Low harm perception mediated the association between advertising exposure (via online, TV, and radio) and ever e-cigarette use and between online advertising exposure and e-cigarette use susceptibility. Regulatory actions are needed to address e-cigarette marketing, particularly on the Internet.

The Racialized Marketing of Unhealthy Foods and Beverages: Perspectives and Potential Remedies.

We propose that marketing of unhealthy foods and beverages to Black and Latino consumers results from the intersection of a business model in which profits come primarily from marketing an unhealthy mix of products, standard targeted marketing strategies, and societal forces of structural racism, and contributes to health disparities.

Public Health Roles in Addressing Commercial Determinants of Health.

The shared challenges posed by the production and distribution of health-harming products have led to growing recognition of the need for policy learning and transfer across problems, populations, and social contexts. The commercial determinants of health (CDoH) can serve as a unifying concept to describe the population health consequences arising from for-profit actors and activities, along with the social structures that sustain them. Strategies to mitigate harms from CDoH have focused on behavioral change, regulation, fiscal policies, consumer and citizen activism, and litigation. While there is evidence of effective measures for each strategy, approaches that combine strategies are generally more impactful. Filling gaps in evidence can inform ways of adapting these strategies to specific populations and social contexts. Overall, CDoH are addressed most effectively not through siloed efforts to reduce consumption of health-harming products, but instead as a set of integrated strategies to reduce exposures to health-harming commercial actors and activities.

Measuring the Commercial Determinants of Health and Disease: A Proposed Framework.

The commercial determinants of health (CDoH) describe the adverse health effects associated with for-profit actors and their actions. Despite efforts to advance the definition, conceptualization, and empirical analyses of CDoH, the term's practical application to mitigate these effects requires the capacity to measure the influences of specific components of CDoH and the cumulative impacts of CDoH on the health and well-being of specific populations. Building on the Global Burden of Disease Study, we begin by conceptualizing CDoH as risk factor exposures that span agency and structural influences. We identify 6 components of these influences and propose an initial set of indicators and datasets to rank exposures as high, medium, or low. These are combined into a commercial determinants of health index (CDoHi) and illustrated by 3 countries. Although now a proof of concept, comparative analysis of CDoH exposures by population, over time and space, and their associated health outcomes will become possible with further development of indicators and datasets. Expansion of the CDoHi and application to varied populations groups will enable finer targeting of interventions to reduce health harms. The measurement of improvements to health and wellness from such interventions will, in turn, inform overall efforts to address the CDoH.

What we can learn from U.S. food policy response to crises of the last 20 years - Lessons for the COVID-19 era: A scoping review.

The U.S government has historically responded to human, natural and economic disruptions that threaten food insecurity by modifying federally-funded public food programs. The authors conducted a scoping review to identify and summarize available evidence on the efforts of a 20-year period to modify food benefit programs in response to emergencies; describe how food benefit programs interact to support vulnerable populations; identify key facilitators and barriers to effective implementation and impact; and assess relevance of evidence to COVID-19 pandemic. Scoping reviews address broad research questions aimed at mapping key concepts and available evidence in a defined area, and include academic and gray literature and reports from governments and NGOs. This review followed the PRISMA Extension for Scoping Reviews and included a three-stage search strategy. Studies were independently screened for eligibility by two researchers with multiple rounds of review. A content based charting method was used to summarize evidence. More than 2289 documents were identified and screened. After review, 44 documents were analyzed. Only 18% of documents reported program or policy impact data. Additionally, review of 149 policy records from State by State FNS Disaster Assistance Data from Oct 2016-Dec 2020 assessed 96 state specific food policy responses to 72 distinct events. Analysis revealed 53 distinct packages of food policy modifications used in response to crises. This scoping review demonstrates that few studies document the impact on food insecurity of food benefit modifications in response to crises. Most documents present output level details about costs and total number of individuals served. Many documents describe food policy response to crises without providing evaluation of response. Analysis points to SNAP and Child Nutrition Programs as most commonly modified food benefit programs in the wake of U.S. crises. The review concludes with a number of considerations for continued response to the ongoing COVID-19 crisis.

Defining Priorities for Action and Research on the Commercial Determinants of Health: A Conceptual Review.

In recent years, the concept of commercial determinants of health (CDoH) has attracted scholarly, public policy, and activist interest. To date, however, this new attention has failed to yield a clear and consistent definition, well-defined metrics for quantifying its impact, or coherent directions for research and intervention. By tracing the origins of this concept over 2 centuries of interactions between market forces and public health action and research, we propose an expanded framework and definition of CDoH. This conceptualization enables public health professionals and researchers to more fully realize the potential of the CDoH concept to yield insights that can be used to improve global and national health and reduce the stark health inequities within and between nations. It also widens the utility of CDoH from its main current use to study noncommunicable diseases to other health conditions such as infectious diseases, mental health conditions, injuries, and exposure to environmental threats. We suggest specific actions that public health professionals can take to transform the burgeoning interest in CDoH into meaningful improvements in health. (Am J Public Health. 2021;111(12):2202-2211. https://doi.org/10.2105/AJPH.2021.306491).

Breaking Bad Patents: Learning from HIV/AIDS to make COVID-19 treatments accessible.

The COVID-19 pandemic has brought renewed attention to the topic of challenging drug patents in the interest of public health. Pharmaceutical companies have already begun to patent existing medicines for the treatment and prevention of SARS-CoV-2, affording them exclusive manufacturing rights over vital medicines. Advocates have raised concerns regarding the pricing of COVID-19 drugs, as well as patent monopolies on the manufacture of COVID-19 treatments. The HIV/AIDS pandemic provides a useful lens through which we can analyse existing pathways for challenging pharmaceutical patents in the context of global pandemic. In this article, we review three legal pathways for overriding and seizing patents on medicines by describing cases in which they were employed to make antiretroviral drugs more accessible to people living with HIV. Last, we highlight the weaknesses inherent in these pathways and offer advocacy and policy suggestions for how to strengthen these pathways to improve access to COVID-19 treatments as they become available in the United States and globally.