Even before setting foot in medical schools across the country, prospective applicants learn the importance of the social determinants of health – non-medical factors that influence health outcomes across the lifespan. From income level, education, housing and working conditions to the lack of affordable health care, food insecurity and discrimination, a plethora of social determinants influence the health of individuals throughout their lives.
During undergraduate medical education, students learn that the conditions in which patients grow, work and live, are central to their wellbeing, contribute significantly toward the development of illness and play a large part in the emergence of health inequities. Throughout residency and fellowship, the impacts of these social determinants become apparent as they constantly present themselves in the clinical setting. Thus, a great deal of emphasis and resources have been placed on teaching and learning about the social determinants of health throughout medical education.
In recent years, however, a novel focus has arisen within the field of population health. The commercial determinants of health (CDOH), defined by the World Health Organization as private-sector activities that affect people’s health – directly or indirectly, positively or negatively – are integral to the health of individuals, groups and societies across the globe. In many ways, the actions of the private sector, from small businesses and national companies to mega-corporations and international conglomerates, deeply influence the physical, social and cultural milieu of civil society. CDOH have only recently emerged as a unifying concept across both public health and medicine, with an increasing number of researchers studying various health crises worldwide.
One of the most obvious examples of the effects of CDOH is the direct impact of the pharmaceutical industry on physicians and patients, an industry that continues to significantly influence physician prescribing and other clinical practices. Free medication samples, sponsored meals and gifts, as well as industry-sponsored medical education programming, travel, research grants and studies are just some of the many common ways the industry exerts its influence on physicians and, by direct extension, the health of many patients.
Another prime example is the development of the highly effective COVID-19 vaccines. Despite the discoveries underlying the technology in mRNA vaccines being heavily subsidized by American taxpayers, the profits went only to pharmaceutical companies and their shareholders. Vaccine manufacturers overcharged some desperate countries in their vaccine contracts with terms and conditions that were overwhelmingly one-sided and strongly favoured manufacturers’ bottom lines rather than prioritizing the health and wellbeing of people in a once-in-a-century global emergency. Thus, access and affordability of lifesaving vaccines was controlled by pharmaceutical companies for billions of people worldwide.
But the impacts of CDOH go much further.
From the food we eat and the transportation we take to the environment we live and work in, CDOH continue to penetrate all facets of our lives. Whole domains of public health and medicine such as firearm safety, tobacco cessation, and healthy eating have been developed to address commercial interests that threaten the health and wellbeing of the population. It is imperative to note that CDOH are firmly entrenched and continue to expand at an ever-accelerating pace. This is due to the fact that the private sector continues to lobby governments at all levels to influence a host of policies and laws to its benefit, particularly with regard to labour conditions, climate change, supply chains, research funding and subsidization, product contents, design and marketing of manufactured goods and even health insurance.
A few specific examples of the impacts of the commercial determinants of health are as follows:
- Intensive animal agriculture, such as factory farming, is a leading cause of climate change, deforestation, antimicrobial resistance as well as air, soil and water pollution.
- Company lobbying, price-setting and targeted marketing strategies promote products including breast-milk substitutes, ultra-processed foods, tobacco, alcohol and sugar-sweetened beverages that can lead to chronic non-communicable diseases in consumers.
- Migrant farm workers in Canada work excessive hours with little access to overtime pay, are denied access to health care, and forced to live in inhumane living conditions.
Faculties of medicine across Canada need to take the initiative to bring the commercial determinants of health into their medical curriculum. For example, by allowing students to analyze in-depth case studies that showcase the tobacco industry’s complex efforts to capture new generations of users or the extensive lobbying conducted by opioid manufacturers that has led to the present-day opioid epidemic, medical graduates can gain the fundamental skills required to map industry practices across sectors. Experiential learning opportunities through field placements can further provide students the chance to work with government agencies, businesses and non-governmental organizations, allowing them to gain practical knowledge and experience in addressing how the CDOH influence health. In this way, future physicians will be equipped with the critical skills and knowledge necessary to make informed clinical decisions and navigate a world in which private-sector interests and actions have profound effects on the health of the patients they serve.
Ultimately, by promoting healthy cross-industry regulation and challenging and scrutinizing the role that private interests play in the health-policy arena, health-care professionals will help further safeguard the health of their patient populations.