Q&A: How commercial determinants of health worsen racial inequities
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* Minoli Ediriweera

Consumers around the world are exposed to a dizzying array of commercial products, not all of which are beneficial to their health and well-being. But awareness of the influence that commercial determinants have on health is growing: This spring, *The Lancet* published a series on the topic and the World Health Organization is planning a dedicated global report and conference in 2024.

Nicholas Freudenberg, MPH, DrPH, a professor of community health and social sciences at the City University of New York’s School of Public Health, who focuses on the impact of marketplace products on public health, contributed to *The Lancet* series.

## Public health workers are very familiar with social determinants and how they influence health outcomes. How do social determinants relate to commercial determinants?

Commercial determinants are fundamental influences on social determinants: housing is a social determinant, health care is a social determinant, food access is a social determinant, and each of those are in turn shaped by certain commercial influences.

Tobacco, fast food, fossil fuels and alcohol are usually cited as commercial determinants.

Tobacco is sort of a prototype because tobacco is good for nobody. There’s no health benefit of tobacco use. Tobacco is the leading cause of premature death and preventable illness, and has been recently overtaken or matched by unhealthy food.

When our focus shifts from the products to the practices — the marketing interfering with democratic processes, the industry consolidation to reduce the power of government — we see those practices cut across many industries.

There’s an increasing interest in how commercial interests are distorting health care and reducing access to needed care and essential medicines.

![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/53/6/11/F1.medium.gif)

[Figure1](http://www.thenationshealth.org/content/53/6/11/F1)

Alcohol is one of four commercial determinants of health that cause significant harm.

Photo courtesy FotografiaBasica, iStockphoto

> “There’s an increasing interest in how commercial interests are distorting health care and reducing access to needed care and essential medicines.”
> 
> — Nicholas Freudenberg

## What led you to study commercial determinants of health?

We need to help individuals change behavior, but often the forces that were leading to unhealthy behavior operate at higher levels.

I came to see the influence of corporations and other business organizations, and therefore wanted to expand the paradigm of public health, from changing individual behavior only to also changing corporate and business behavior.

## How do these commercial interests drive health inequities?

It’s not that business owners say, “How can we hurt poor people or Black people or children?” But rather that they follow the rules of the system, which tell them to maximize profits.

In this country, untapped markets are oftentimes poor people, people of color. So, as they saturate the markets for whatever it is — cars, tobacco, fashion — they look to move from better-off people to poor people.

A lot of my own work has been about marketing unhealthy food to children, what we sometimes call predatory marketing, where the food company profits at the expense of their well-being.

There’s a lot of empirical work documenting how unhealthy food marketing targets Blacks, Hispanics, children, low-income populations, and there are characteristics of our food system, because unhealthy food is often cheaper and more available and certainly more heavily advertised than healthy food.

People who have limited incomes or limited time to cook end up eating this unhealthy food, and the fast food companies and highly-processed food companies realize that is where their profits come from. So they double down and do more of that marketing.

## What can policymakers do to address these problems?

In London, they banned the marketing of unhealthy food in the public transit system. They have now shown that has reduced consumption of unhealthy food among children. That’s a very clear example. A city said, “This transportation system belongs to us, and we can set the rules of what gets advertised, and since children are exposed to this advertising on their way to school, it’s not ethical or in the interest of our society.” Now they’re seeing health benefits from that.

Many of the efforts to reduce the use of fossil fuels are other examples of government action often forced by activists and social movements, which have often played a role in changing public policy.

Another strategy has been to put taxes on unhealthy products. That has also been tried in a bunch of different places and shown to lead to reduced consumption, specifically in the populations most burdened by unhealthy food-related diseases.

![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/53/6/11/F2.medium.gif)

[Figure2](http://www.thenationshealth.org/content/53/6/11/F2)

A customer visits an outdoor store in Cebu City, Philippines, in 2013. Companies often market high-calorie, low-nutrition food and beverages to people who are low income and communities of color. More policymakers are recognizing the dangerous influence of commercial products — including the marketing of unhealthy food to children — on public health.

Photo by TomFullum, courtesy iStockphoto

## Are commercial determinants getting their due in public health studies?

There’s a really important question of how we can bring this subject into schools of public health. There are a handful of schools that have been teaching this.

My colleagues and I have been teaching courses on this for a while now. APHA, the Council of Education for Public Health, schools and programs should be looking to develop the capacity of public health faculty and schools to teach about this.

## How can public health workers raise awareness of this influence?

The public needs to know how those decisions get made. Should food companies be able to profit by selling products (associated with) diabetes and cancer and other diet-related diseases? Should they be able to market to children with limited or no restrictions?

If we’re concerned about children’s health and we’re concerned about obesity, then we need to look at the forces that are encouraging that and take action to reduce them.

*   Copyright The Nation’s Health, American Public Health Association