Does the Private Sector Help, or Hinder, Life Expectancy?

— Analyzing the impact of the "commercial determinants of health"

by N. Adam Brown, MD, MBA, Contributing Writer, MedPage Today,

August 13, 2024

Earlier this year, the CDC announced that life expectancy in the U.S. had risen to 77.5 yearsopens in a new tab or window. Of course, that number is just an average. If you grew up in Mississippiopens in a new tab or window, you're not expected to live to see 72. Meanwhile, the average life span for residents of Hawaii is 80.

Many Americans now understand that social determinants of health (SDOH) -- where a person lives, their education and income, and even ease of access to transportation -- can affect longevity.



While these factors remain crucial in shaping health outcomes, a growing body of evidence suggests private companies play an equally significantopens in a new tab or window, and maybe more insidious, role in determining health outcomes for individuals and communities. These companies control the commercial determinants of health: actions, policies, and practices executed by private-sector entities that directly or indirectly influence public health.

What Are Commercial Determinants of Health?

Unlike SDOH, which are generally the result of government policies and priorities, family legacy and background, and economic pressures, commercial determinants of health (CDOH) are driven by the decisions made by private enterprises. They encompass a wide array of business considerations, including the desire to attain a certain profit margin, the durability of supply chains, labor conditions, product design and packaging, research funding, lobbying, and marketing practices.

CDOH can have both positive and negative effects, shaping the social, physical, and cultural environments in which people live. The choices made by companies in the production, pricing, and marketing of products like ultra-processed foods, tobacco, and sugar-sweetened beverages have been linked to an increase in noncommunicable diseases such as cardiovascular disease, type 2 diabetes, and certain cancers, for example.

The aggressive marketing tactics employed by these companies, especially when targeting young people, exacerbate these health issues. Advertising fast food to teenagers, for instance, taps into the highly sensitive and still-developing pathways in their brains, making them more susceptible to unhealthy eating habits that can lead to obesity and related health problems. Similarly, the promotion of alcohol and tobacco through celebrity endorsements and social media influencers often glamorizes these products, encouraging consumption among impressionable audiences.

The Hulu series Dopesickopens in a new tab or window, which explores the origins and causes of the opioid epidemic, and the 2006 movie Fast Food Nationopens in a new tab or window both examine how commercial decisions affect health -- but the impact of CDOH extends far beyond these well-known examples. The environmental consequences of commercial activities like mass deforestation to meet global demand for commodities -- like timber, tobacco, and coffee -- can lead to outbreaks of vector-borne diseases such as malaria and chikungunya.

According to a 2020 articleopens in a new tab or window published in Nature, up to 20% of malaria risk in deforestation hotspots can be attributed to international trade. And, of course, as the American Hospital Associationopens in a new tab or window has pointed out, "Many commercial health insurance policies and practices often disrupt, delay and deny medically necessary care to patients."

On the flip side, pharmaceutical companies play a crucial role in increasing the availability of essential medicines and health technologies, and improving access to high-quality, safe, and effective medical products. The reformulation of goods and products to reduce harm is another area where commercial entities have made significant strides. For example, the introduction of seat beltsopens in a new tab or window by the automotive industry (an invention from the 1880s), efforts to reduce salt contentopens in a new tab or window in food production, and the elimination of trans fatsopens in a new tab or window from the global food supply are all examples of how private sector initiatives benefit public health. Admittedly, while public outcry, laws, and regulations hastened some changes, others have been quickly recognized as a public good.

How the Private Sector Can Leverage Commercial Power to Address SDOH

Commercial determinants of health do not exist in a vacuum; they interact with and often exacerbate the effects of SDOH. Ultra-processed foods are more likely to be consumed by individuals living in economically disadvantaged communitiesopens in a new tab or window, for example, where access to healthy food options and healthcare services is limited. Young people are particularly vulnerable to the influence of marketing and advertising, making them more susceptible to the allure of harmful products.

The fact that social and economic inequities can be worsened by the effects of CDOH underscores the importance of government regulation of the commercial activities that target vulnerable demographics, as well as the need for public health campaigns that balance these influences. It is essential that lawmakers create a regulatory environment that encourages responsible corporate behavior while holding companies accountable for the negative impacts of their actions. Lawmakers also should consider incentives for companies to invest in health-promoting activities and products.

The private sector also must police itself. In 2018, just days after a mass shooting in Florida, the CEO and largest shareholder of Dick's Sporting Goods decided that his company would no longer sell guns (following an initial scale back in 2012 following the Sandy Hook Elementary School shooting). As CNN explainedopens in a new tab or window, the company started slowly, first announcing it would stop selling semi-automatic weapons, and then pulling firearms and hunting accessories from 10 stores as a test.

The decision was the right thing to do for public health -- and for the bottom line. At those 10 stores, "Overall sales increased." The last quarter of 2023opens in a new tab or window was Dick's Sporting Goods' most profitable 3 monthsopens in a new tab or window in the company's history.

Corporate policies that promote living wages, paid parental leave, sick leave, and access to health insurance also can significantly improve health outcomes, particularly for vulnerable populations. These positive effects of CDOH highlight the potential for the private sector to be a force for good, provided that there is a commitment to prioritizing public health over profit.

While the commercial market has the potential to contribute to improved public health, it also poses significant risks, particularly when profit motives overshadow public health considerations. As we continue to address the social determinants of health, it is imperative that policymakers and the healthcare industry also focus on the commercial determinants, holding the private sector accountable for the role it plays in promoting the health and well-being of all people. By doing so, we can create a healthier, more equitable society where the pursuit of profit does not come at the expense of public health.