More than a quarter-century ago, I wrote an article called “Caveat Partner” about the problematic aspects of public health creating partnerships with the private sector.
More broadly, I was concerned with the adverse health impacts of many of the ways in which the private sector works — its products and services, the way it produces and markets them, and its indirect adverse effects on economic and social policy.
This was hardly a new problem. Conflicts between the private sector and public health have been going on for at least 700 years. This was revealed in a fascinating book by the Italian historian Carlo Cipolla almost 50 years ago. He described the boards of health in the city-states of 15th century Renaissance Italy, which had broad powers to regulate public gatherings, enforce quarantine laws, issue health passes and carry out inspections.
Their efforts to fight the spread of plague through quarantine, fumigation and the embargoing of goods could have a dramatic impact upon trade due to declining exports, destruction of unfinished goods, unemployment, social unrest and even revolt.
As a result, they were subject to severe pressure from the merchants, whose economic wellbeing was affected. Meanwhile, the boards’ health officers complained about the ignorance of the populace, the disregard of their ordinances, the hostility of the merchants and the need to effect compromise between public wellbeing and economic necessity.
Four centuries later, as the 19th-century public-health movement struggled to overcome the health problems resulting from industrialization and urbanization, nothing much had changed.
When their mercantile interests were threatened, many industrialists opposed legislation and regulation that directly affected them, such as child labour laws, laws relating to working conditions and legislation to control pollution. Sometimes they simply objected to raising and spending taxes on public works such as sewers, water works, and the like.
With this and much more history in my mind, I nonetheless began my 1998 article by stating: “I see nothing inherently evil in the private sector, nor anything inherently wrong about partnership with the private sector. After all, the private sector grows my food, builds my house, creates employment and in a myriad of ways meets our basic and not-so-basic needs.”
But — and it’s a big but — too often there is a major conflict between public health and large segments of the private sector because they have two very different motivations. “The motivation that underlies the private sector,” I wrote, “is very clear — profit. The motivation that underlies the health promotion sector is also very clear — better health for all and a narrowing of the health gap between rich and poor. These motivations are not necessarily incompatible, but nor are they necessarily compatible.”
So here we are, 700 years later, still struggling with the private sector. Now the World Health Organization itself has begun to focus on the theme of what it calls the commercial determinants of health by establishing a new initiative on the economic and commercial determinants of health.
In a commentary in a special series on the commercial determinants in The Lancet in April last year, WHO director-general Dr. Tedros Ghebreyesus was blunt: “Many major risk factors for disease and injury, such as tobacco, alcohol, and ultra-processed foods, are major industries and profit-drivers for powerful transnational companies.”
He could have added the fossil fuel and automobile industries and many others.
But the WHO’s concerns are broader than these fairly obvious threats to public health. “When profits are threatened,” he added, “some companies and other actors with vested commercial interests deliberately undermine public health policies.”
He also expressed a broader concern with the way the international system “supports the drive for ever-increasing profits and economic growth over the social, environmental and health impacts of commercial products or practices.”
In his commentary, Dr. Ghebreyesus noted that in 2024, the WHO would be organizing a global conference on the topic and would publish the first WHO global report on the commercial determinants of health.
So over the coming weeks, I will delve into the commercial determinants of health, what the WHO is doing and what is involved in addressing them in Canada, in B.C. and locally.
Dr. Trevor Hancock is a retired professor and senior scholar at the University of Victoria’s School of Public Health and Social Policy.
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