Widening the lens of the social and commercial determinants of health

Alcohol, tobacco, ultra‐processed foods and sugar‐sweetened beverages — these are the types of harmful products that tend to spring to mind when we think about the role of commercial actors and behavioural factors in influencing health. And for good reason. In Australia, for instance, smoking is estimated to kill more than 24 000 people each year.1 Alcohol contributes substantially to a wide range of diseases, including cancer, liver disease, heart disease, and suicide and self‐harm, and overall accounts for around 4% of the nation’s total disease burden.2 Reducing the consumption of sugar via a sugar‐sweetened beverage tax is predicted to substantially reduce the number of cases of type 2 diabetes, heart disease and stroke, while also cutting the prevalence of obesity in children and adolescents.3

Traditionally, scholarship in this area has focused on industries that produce and sell products with obvious health harming impacts. More recently, the understanding of the commercial determinants of health has expanded to encompass the “pathways through which commercial actors drive health and equity”.4 This shift has enabled more deliberate exploration of how many other sectors of the economy can influence health, including gambling, social media, housing and education, to name but a few.5

This issue of the MJA illuminates our evolving understanding of the role that social and commercial factors have on health in Australia. Two articles in this issue address how rising rates of homelessness — which includes sleeping rough, as well as reliance on emergency and temporary accommodation, couch surfing, and substandard housing — demand greater consideration from health policy makers and practitioners. First, Stearn and colleagues6 explain how housing insecurity adversely affects cancer care and outcomes and put forward several possible pathways towards achieving more equitable cancer outcomes for people experiencing homelessness. Second, English and colleagues7 explore the intersection between the worsening climate crisis and homelessness. They outline the evidence on how people experiencing homelessness are more vulnerable than people with secure housing to the health impacts of extreme heat and describe emerging public health responses, including their world first co‐designed mobile cooling hub.

Turning to health care, a perspective article by Murphy8 explores the rise in out‐of‐pocket costs for accessing non‐general practitioner specialists. “Doctors have, not unreasonably, had an expectation of earning high incomes, given the training required for each specialty fellow,” Murphy argues. “However, these incomes, and the fees that generate them, have created a number of challenges.” Several possible solutions are discussed, with Murphy concluding “self‐regulation is the simplest option. Given the community and government angst about this issue, specialists would do well to reflect on the impact of their fees on patients … [to] improve patient access and reduce the risk of government intervention”.

Other work in this issue of the MJA includes new research by Egger and colleagues9 on trends in adolescent smoking prevalence, which suggests vaping might be slowing Australia’s tobacco control progress. In addition, a narrative review by Cortes‐Ramirez and colleagues10 examines the relatively understudied effects of mining activities on the health of Australians, and a whole of population census data analysis by Gong and colleagues11 characterises the relationship between socio‐economic position and the prevalence of ten leading chronic diseases.

Despite our expanding understanding of the social and commercial determinants of health, until very recently the news media industry has attracted little attention from public health scholars.12 Writing in this issue of the MJA, Fredericks and colleagues13 make a case for establishing journalism as a health determinant and for protecting public interest journalism as a public health good. “Our increasingly unreliable and unsafe news and information environment has profound and wide‐ranging implications for the health sector and the health and wellbeing of communities”, they argue. Yet “at the same time, the capacity of public interest journalism has been greatly diminished”. Fredericks and colleagues outline how responses to the spread of health‐related misinformation and disinformation are frequently too narrow in focus. Strategies such as improving science communication or health literacy are important, but on their own will fail to address the complexity and connectivity of the issues at play. Rather, systems approaches are required that recognise the central role of public interest journalism in “hold[ing] to account the commercial and political interests undermining the safety and reliability of news and information systems”. Crucially, the authors highlight how “Indigenous knowledge systems have much to offer to systemic analyses and responses because of their dynamic, adaptive and holistic approaches with the capacity to connect diverse spheres”.