Dr. Norah Campbell:

I am normally used to boring my students or fellow researchers about this, so I am really grateful for this opportunity which I feel is so important because I am trying to communicate that a lot of international research is being done in this field and it is very different from what the committee may already know about health policy and population health. Traditionally, governments have tended to focus on the final routes to ill health. That means examining an individual’s consumption of an unhealthy product and using clinical treatment, education or behavioural change to do these interventions.

Since the 1980s, there has been a second way or paradigm of health because governments began to think about these really powerful ways in which an environment shapes and constrains individual’s behaviours. They began to focus on marketing and advertising and working with industries to enact corporate social responsibility.

I have been asked here today to give members an overview of a third paradigm - the commercial determinants of health. This is a term being used to account for the many ways commercial activity shapes population health by capturing health policymaking. There is a large body of recent research spanning epidemiology, business studies and policy studies that is mapping these commercial pathways, and proposing policies that can effectively address them. This work is focused on the causes of causes of disease.

I will start by saying that businesses are the lifeblood of this country and commerce is a fundamental indicator of a thriving community. Commerce safeguards health through, for example, providing us with essential medicines, eliminating trans-fats from our diets and giving us work and material wealth. Some businesses have disproportionately negative effects on human health. In March last year, The Lancet, which is a really conservative medical journal, calculated that at least one third of global deaths are attributable to just four industries: the tobacco industry; the ultra-processed food industry; the alcohol industry; and the fossil fuels industry. It is important to note that these industries are dominated by a small number of large companies with distribution power and budgets for policy and public norm shaping. It is also important to note that every country faces pressure from these commercial actors due to their disproportionate resources to shape what is known as the knowledge environment.

Their commercial activities are designed to make their products as cheap, readily available and desirable as possible. That is their mission. Research has shown how their supply chains, product design, packaging and their distribution directly increase the risks for poor health through smoking, air pollution, alcohol use, and obesity.

More subtly and profoundly, commercial actors influence public policy on health, by influencing how health problems are famed in the media, through lobbying key government departments and policymakers and through shaping preferences and cultural norms. For example, they shape how health problems are understood - for example, that obesity can be solved by just simply building health literacy and exercise, that alcoholism is a predominantly genetic disease and only infects a minority, or that vaping is an effective smoking cessation tool and nothing else.

The tasks of public affairs departments, PR firms and industry lobby groups are to work to prevent or weaken regulation on their client's behalf. That is their sole mission. They do this chiefly by promoting forms of self-regulation with policymakers. These political activities disproportionately shape this country's trade policies and our finance and investment flows. This in turn shapes health by further proposing and normalising unhealthy commodities.

Commercial determinants shape and drive inequalities. These commercial determinants impact citizens who are not profiting from the product or service that causes harm to their health and are instead faced with the burdens of these harms.

In other words, risk is not spread evenly. Young people and the poor are more vulnerable to those determinants. Anyone who walks around Ireland today will have no problem seeing that disparity. I also argue, however, that governments are vulnerable groups. The graph I included shows that governments are in this vicious cycle of smaller state budgets and absorbing the increasingly high health externalities of commercial actors, which are recording record market growth.

There are three important realities about population health I need to tell the committee about. The first, and this is collated from research on the commercial determinants of health, is that treatment will never solve the problem. Research shows that 50% of good health is dependent on socioeconomic factors, including salary, family support and the safety of the community people live in. Approximately 50% of people's good health is attributable to that. There is an idea that behavioural change has this massive impact but approximately 30% of good health is attributable to behaviour, and only 20% is attributable to people’s access to healthcare. We need to keep that in mind. The "treatment trap’" is a term used to describe how governments have been forced to focus on the urgent and visible wins in healthcare, such as hospital beds and GP provision, while being left under-resourced and depleted to deal with upstream prevention policies.

The commercial determinants of health paradigm realises that governments need a small number of structural changes rather than large numbers of small changes. I am here to say that every little does not help. It creates noise and distracts from making the couple of big changes that harmful industries would actually worry about. The paradigm shift is from treatment to prevention. This perspective asks that policymakers position health interventions along a continuum. It is not about doing all of this together and tackling big things and small things at once, but rather a continuum of doing upstream things first and then downstream things, and measuring the efficacy of these interventions. It is about moving away from interventions that place high demands on individuals, such as people educating themselves, becoming health literate, behavioural change campaigns, and this kind of nudge ideology. These are not effective. They have been shown to be ineffective compared with structural, fiscal and pricing changes and distribution access. In the treatment role, government is mopping up an increasing spill, while in the prevention role, it is turning off the tap.

The profit imperative is a natural law. I work in a business school, where I have been for the past 17 years. I am a beneficiary of business but companies make choices in the production, price setting and targeted marketing of products to make them maximally available, convenient, seductive and cheap. That is not the fault of any individual working in these organisations. It is their fiduciary responsibility and a professional norm. I do not think you would ever meet a manager who wakes up in the morning and says, "I cannot wait to make another child overweight" or "I cannot wait to make another woman dependent on daily alcohol consumption." That is just not the way it works. The operating space of these industries is determined by government incentive and disincentive. These are structural instruments that are only at the disposal of government.

A paradigm shift is happening. The unit of analysis has changed and health is more about tax, and subsidy, pricing and distribution changes, than it is about physiology.