KUALA LUMPUR, July 21 – Last year, the World Health Organization (WHO) released a report attributing one-third of global mortality to just four industries: ultra processed foods, fossil fuels, alcohol, and tobacco.
According to the report, these industries cause 19 million deaths per year globally, or 34 per cent of all deaths.
“It’s phenomenal as a statistic. We can count the number of companies that this represents,” said Monica Kosinska, global head of Economic and Commercial Determinants for WHO, during a symposium on global health governance by the United Nations University International Institute for Global Health (UNU-IIGH) in Kuala Lumpur last April 22.
“For this region in the Western Pacific where we sit, the figure goes up to 48 per cent. Almost 50 per cent of all mortality in this region is attributable to four industries.”
She added that Malaysia fared slightly better than the global average with a 30 per cent mortality rate from those industries.
“But every country, every region faces its burden. And every single one of these deaths is unfair, unjust, and preventable,” Kosinska said.
Commercial Determinants Of Health
While it has been known for decades that commercial actors and commercial practices have consequences on health and health equity, it was around 10 years ago that the global public health community started conceptualising commercial forces as a common set of determinants known as the commercial determinants of health.
WHO defines the commercial determinants as all activities and systems in which commercial activity takes place, said Kosinska. In simpler terms, it is the systems, practices, and pathways through which commercial actors drive health and health inequity.
“Our knowledge about the rise in harms arising from commercial actors and commercial practices also coincides with the rise of the role of the private sector in global health,” Kosinska said, adding that this “has fed and shaped the world that we’re living and working in in global health terms.”
While she acknowledges that not all private sector partnerships are bad, with some being important for the work in global health, Kosinska said there has been a growing understanding and recognition that private sector practices are at the heart of the most pressing global health challenges today.
Commercial actors impact health and health inequity in a variety of ways. “Many of us start our work in commercial standards looking at marketing and take that all the way through to reputation management, political contributions, and even financial,” she said, adding that as an intergovernmental organisation, it was important for WHO’s work to be rooted in the social determinants of health.
“(This) challenges us as an international community to address the imbalances in resources, in the distribution of money, power, and resources. And this is really the heart of what we do.
“When we think about commercial practices and commercial actors and their role in global health and health equity, we cannot fail to start with the equity lens on outcomes. The distribution of what we are talking about is unfair, it’s unjust, and it’s unequal.”
But there are also external factors to consider such as who pays and who benefits commercially, and how this impacts society and governments, she said. As such, there is a need to prioritise the identification and management of conflicts of interest, in terms of how it is defined, supported and prevented.
Rooted In Deep Power Imbalances And Colonial Legacies
Kosinska added that commercial practices and commercial actors cannot be seen as separate from the broader economic and financial environments. “Effective action means seeing this as an embedded system” with the aim of “(preventing) public health harms and safeguarding (against) conflicts of interest whilst leveraging the potential of the commercial sector to improve health outcomes and health equity.
“It is about how we can protect public health in the processes that we’re talking about whilst leveraging the co-benefits when we can.”
In order to do that, there are certain assumptions that have to be considered, she said. “Because they really form the basis in terms of how we’re able to take some of this forward.
“The first assumption is that commercial actors will continue practises that prioritise profit over health and the determinant impacts, unless they’re required not to do so. And this is very self-evident for a lot of us.
“So when we’re asking commercial actors to be partners in processes, while we’re asking them to contribute to public health and global health, we have to remember that they are bound by rules that institutionalise a requirement to put profit over public health interest.
The second assumption is that the negative outcomes emerge from power asymmetries and imbalances, she continued. “And that’s very important for our third assumption, which is that these power imbalances and asymmetries are modifiable. We can change them, and we must.”
The commercial determinants of health are rooted in deep power imbalances and colonial legacies, Kosinska said. “That means we have to think about this very firmly in what we want to do to make change.”
Global Health In Existential Crisis
Historically, global health has been affected by a half-century of neoliberal global dominance, which has given rise to interrelated crises that have posed survival threats, said Ron Labonte, professor emeritus, School of Epidemiology of Public Health, University of Ottawa.
Neoliberalism is an economic ideology that emphasises the value of free market competition and is most often associated with the laissez-faire doctrine of minimum governmental interference in business and economic affairs.
Its key doctrines of privatisation, deregulation, liberalisation, and minimal taxation are diffused globally through the policies of international financial institutions like the World Bank and the International Money Federation (IMF) that impose them as conditions of their structural adjustment programmes, which provide loans to countries in economic crisis.
“Now, taking just one of neoliberalism’s key tenets, that of taxation, neoliberalism precipitated a steady erosion in marginal income and corporate tax rate, in a kind of competitive race to the bottom,” said Labonte.
“The structural adjustment programmes of the IMF and World Bank internationalised the low-tax regime, shrinking the amount of global economic product that states could harvest for public good purposes.”
According to him, in 2002 — the first year global level data became available – the amount of untaxed income was almost US$30 trillion (approximately RM127.38 trillion).
In 2019, the last year Labonte said he could consolidate the data, it had reached US$75 trillion (approximately RM318.46 trillion).
By 2022, the global difference between global economic product and taxation, and in terms of value, was US$90 trillion (approximately RM382.15 trillion).
“Now, I’m not saying that we should tax every last dollar, but the sheer amount of private wealth that has been accumulated in this short period of time is absolutely astounding,” said Labonte.
“This growing gap between private wealth and public revenue goes a long way to explain why governments are so reliant on debt to keep afloat, and why UN agencies, including the World Health Organization, are after the spare change of the 0.001 per cent.
“It also explains the electoral drift towards right-wing authoritarian leaders,” said Labonte. “Global health is churning in a chaotic wake. But even before Trump came blasting out of the inauguration gates, fast-tracking to dictatorship, the world’s health was already in an existential crisis.”
He cited rising inequalities, ecological collapse and migration as threats to survival.
“Elon Musk is poised to become the first trillionaire within a few years, even as a billion of us still live in extreme hunger and almost extreme poverty.
“We’ve passed the 1.5 degree red line in global warming and seven out of the nine ecological boundaries essential to sustain life.
“More people are now fleeing poverty due to the chaos, conflict, and climate impacts than ever before, only to be met by more and more hostile boundaries.”
In addition to all those “existential health threats”, the world is seeing “a rise in autocratic regimes, which now outstrip democracies for the first time in over two decades,” said Labonte who is on the steering committee of the People’s Health Movement.
The People’s Health Movement is a global network bringing together grassroots health activists, civil society organisations and academic institutions from around the world, particularly from low and middle income countries, according to its website.
While autocracies can be reversed, it is uncertain “whether this democracy-autocracy pendulum can swing back in a more equitable direction before our existential health crises reach their final tipping points.
“I know most of us are very aware of Trump’s attack on almost everything global health activism has struggled to achieve in the past half-century,” said Labonte, adding that global health security and even more critically, planetary health is at risk.
“The abrupt ending of foreign aid actually should be considered premeditated extraterritorial murders by the outside estimate of the number of people who are going to die simply because of no longer having access to antiretrovirals – up to three million people over the next five years.”
Two Counter Narratives: Degrowth Economics And Wellbeing Economics
However, two counter narratives: degrowth economics and wellbeing economics, have begun emerging as neoliberalism’s role in worsening the current existential crisis has become too evident to ignore, said Labonte.
“Degrowth or post-growth economics takes aim at capitalism’s reliance on increasing consumption of finite resources,” he explained.
“It calls for a deliberate and regulated reduction in excess consumption in high-emitting sectors and countries, a redirection of investment into specific goods and services necessary for improving health and planetary environment, and a redistribution of wealth from rich people and countries to poor people and nations.”
Labonte, who added that the concept has been criticised for being unrealistic, acknowledged that “breaking the ad-incentivised world of mass consumption is certainly not going to be easy.
“But even if we accept that degrowth is unrealistic, it is more unrealistic to assume that a capitalist economy can resolve the very crisis of excess consumption that it requires and that it creates.”
However, one critique of degrowth that has stuck is that it emphasises a negative concept, rather than being a positive, affirming and mobilising concept that speaks to people in an emotional way, said Labonte. This is what wellbeing economics attempts to do.
WHO embraced the concept of wellbeing economics when it established its Council on the Economics of Health for All in June 2020, comprising an all-female group of 10 distinguished economists and experts.
“Over its two-year term, the council issued a series of policy briefs that culminated in recommendations that were intended to transform economic systems and co-create an economic policy design guide to shift beyond GDP growth and instead deliver shared wellbeing,” said Labote.
He added that Earth for All, a publication released in 2022 by The Club of Rome, identifies five great turnarounds to achieve wellbeing for all with very specific policy directives.
According to its website, The Club of Rome is a platform of diverse thought leaders focused on finding solutions to the complex emergencies facing society.
“A few countries are also adopting parts of the wellbeing economics concept, and the WellBeing Economy Alliance with over 400 member organisations continues to try to promote the idea,” Labote continued.
The Wellbeing Economy Alliance (WEAll) is a leading collaboration of organisations, alliances, movements and individuals working towards a wellbeing economy, delivering human and ecological wellbeing, according to its website.
He added that unlike degrowth economics, few wellbeing economy initiatives explicitly call out capitalism or adopt fiscally challenging policies.
“But its positive language of abundance, of wellness and conviviality resonates with what polling tells us many of the world’s people want,” said Labote.
“And that is an economy organised around human and planetary wellbeing rather than around growth and capital accumulation.”
