The commercial determinants of infant and child health
BMJ 2024; 387 doi: https://doi.org/10.1136/bmj.q2395 (Published 31 October 2024) Cite this as: BMJ 2024;387:q2395
Understanding of the multiple determinants of infant and child health has evolved over time, but there’s been relatively little discussion, in relation to infants and children, of what have been termed the “commercial determinants of health.”1 These are defined by the World Health Organization (WHO) as “private sector activities impacting public health, either positively or negatively, and the enabling political economic systems and norms.”2
Considering their effects on young people is an important omission, not only because infants and children are particularly vulnerable but also because health in early life establishes trajectories for adult and population health.3 For this reason the Venice Forum, an international group of academics concerned with improving maternal and child health, met in April 2024 to discuss the issue. Here we present some of the results of our discussions.
Many commercial determinants of health are well recognised and affect all age groups. These include the tobacco, ultraprocessed food, alcohol, and fossil fuel industries, whose products have adverse effects on respiratory, cardiometabolic, and reproductive health, as well as cognitive development. However, children are often specifically targeted by these industries—for example, through advertisements designed to promote sweet drinks, fruit flavoured vapes, and unhealthy foods.
The best known example of a commercial activity affecting early life is infant formula, which cost the lives of millions of infants in the 1980s. The Venice Forum did not discuss this except to note that, as often happens, action to limit one industry fuels growth in another. An example is the commercial human milk industry, where breastmilk is bought at low cost from mothers, often in low income settings, and is then processed, packaged, and marketed for high profit.4
A particular concern relates to the private healthcare industry. This is especially damaging to infants and children, both directly and indirectly. For example, the substantially higher rate of non-medically indicated caesarean sections in the private sector,5 driven by financial benefits for clinicians, increases the risk of respiratory distress in the newborn and may have adverse consequences for immune and metabolic development, through multiple biological pathways.6 Children also have little protection when private sector practitioners persuade parents of the benefits of treatments with little clinical justification, such as tonsillectomy, tongue tie ligation, helmet therapy, and antibiotics for viral upper respiratory tract infections.
Furthermore, a private healthcare sector running in parallel with national healthcare progressively undermines and reduces commitment to public provision, to the point where in the US, for example, even emergency care is routinely provided by the private sector. Children are particularly adversely affected by the withdrawal of public sector services—as shown by the rise in dental caries, which now affects one in four UK children after reductions in NHS dental care and the high costs of private dental care that make dental services unaffordable for families with low incomes.7
Better measures of value
The private sector depends on investment from shareholders, who prioritise profit over the public good and are risk averse. This has discouraged the drug industry from focusing on infants’ needs in favour of more lucrative and lower risk sectors such as adult cardiovascular and cancer treatments, with the result that only one medicine has ever been specifically developed for a newborn condition: surfactant, a highly effective treatment for neonatal respiratory distress syndrome. The major health challenges facing young children, such as overweight and obesity, have seen little investment in terms of prevention.
What can be done to tackle the harms to health while retaining the benefits of commercial activities? WHO initiated a programme on the economic and commercial determinants of health8 with four goals: strengthening the evidence base, developing tools, convening partnerships, and raising awareness. We applaud these, but more is needed.
A conventional approach is to tax products that harm health, but this often simply makes them seem more desirable.9 A more fundamental route would be to place measurable value on health as a crucial determinant of sustainable human progress.10 From this perspective, the focus by most governments on increasing gross domestic product (GDP) is a major problem, as it prioritises economic growth in policy making, often to the detriment of health.
We argue that a focus on net rather than gross domestic product should be adopted, as this measure would be reduced by commercial outputs adversely affecting health and increased by those benefiting health.11 This would also require a re-evaluation of the concept of “product”: for example, we suggest that GDP should include largely unremunerated activities that have major and positive effects on mental and physical health, such as breastfeeding and childcare.12 Relegating health to a dashboard to be monitored in parallel, as proposed by some,13 is unlikely to be effective, as policy makers would likely continue to prioritise GDP. Nor would this shine a necessary spotlight on the commercial determinants of health.
Some actions could be implemented quickly, such as legislation to prohibit harmful products being marketing at children—such as vapes, sugar sweetened drinks, or highly processed foods. In addition, registration of conflicts of interest offers an approach to curbing sponsorship of events and activities by industries manufacturing products that damage health. However, the close and complex inter-relations between public and private enterprise make eliminating all conflicts of interest nearly impossible. Lessons can be learnt from tobacco control, principally the need to exclude health harming industries from lobbying and engagement in policy making arenas, and the need for government actions that resist favouring corporate interests or hindering public interest legislation.14
Healthcare workers and related professionals need to play a larger role in championing this agenda, and their training should include better understanding of the commercial determinants of health. Likewise, educational programmes in schools could raise awareness in parents and children of the need to recognise private sector influence, such as sponsorship of sporting events by the sweetened drinks industry that aims to deflect attention away from the health harms of their products.
Empowerment and agency are powerful drivers of change, so we also applaud an election manifesto pledge made by the UK’s new Labour government to lower the voting age to 16. Infant and child health is the foundation of better population health and prosperity, so it is crucial to devise models for commercial activities that protect against harms while retaining benefits.
Footnotes
Acknowledgements: We are grateful to the following attendees of the Venice Forum meeting in Madrid in April 2024, who each contributed to this paper: Flavia Bustreo, chair, Governance and Ethics Committee, The Partnership for Maternal, Newborn and Child Health, World Health Organisation, Geneva, Switzerland; Gian Carlo Di Renzo, The Permanent International and European School of Perinatal, Neonatal and Reproductive Medicine, Florence, Italy; Anna Gilmore, director, Tobacco Control Research Group and co-director, Centre for 21st Century Public Health, University of Bath, UK; Anne - Beatrice Kihara, president, International Federation of Obstetrics and Gynaecology, Department of Obstetrics & Gynaecology, University of Nairobi, Kenya; Nason Maani, Global Health Policy Unit, School of Social and Political Science, University of Edinburgh, UK; Ariadne Malamitsi-Puchner National and Kapodistrian University of Athens, Medical School, Athens, Greece; Kumanan Rasanathan, executive director, The Alliance for Health Policy and Systems Research, World Health Organisation, Geneva, Switzerland; David Rowland, director, The Centre for Health and the Public Interest, London, UK.
Competing interests: NM has current grants from the National Institute of Health Research, the Medical Research Council, the UK Department of Health, Bayer AG, and Chiesi Pharmaceuticals. In the past five years NM has received a lecture honorarium and travel and accommodation reimbursements from Medela and has been a co-investigator on a study funded by Prolacta, a manufacturer of commercial human milk products. NM was a member of the Nestlé International Scientific Advisory Board from 2018 to 2022 and is a current member of the scientific advisory board of the Singapore Ministry of Health Metabolic Health in Mothers and Babies Programme and the Sophia Children’s Hospital, Erasmus Medical Centre, Rotterdam. NM is a past president of the Royal College of Paediatrics and Child Health, the Neonatal Society, the Medical Women’s Federation, and the BMA and is president elect of the European Association of Perinatal Medicine. MAH has no disclosures to make.
Provenance and peer review: Not commissioned; not externally peer reviewed.