The commercial determinants of health: The mini-budget is a consequence of foundational forces medicine must bear witness to

In the preface to his 1982 book “Capitalism and Freedom,” the influential economist and free-market proponent Milton Friedman wrote: “Only a crisis—actual or perceived—produces real change. When that crisis occurs, the actions that are taken depend on the ideas that are lying around. That, I believe, is our basic function: to develop alternatives to existing policies, to keep them alive and available until the politically impossible becomes the politically inevitable.”1

There is little doubt that the mini-budget announced last week represents a distillation of this philosophy. The changes are certainly real. Economic orthodoxy was thrown to the wind2 as the UK government embarked on a wide-ranging package of tax cuts at a time of exceptional pressure on public finances and great precarity for the most vulnerable people in the population. Political promises were similarly discarded as a party elected on a commitment to “levelling up” implemented measures that will benefit only those earning over six times median income.3

The ideas in the mini-budget are those “alternatives” that Friedman spoke of, stored away until the right moment arose. As the environmental commentator George Monbiot has noted,4 environmental and economic deregulation and tax cuts for wealthy individuals and corporations have long been kept alive by a collection of free-market thinktanks whose funding is opaque but are known to attract support from high net worth individuals and companies whose products threaten health, including British American Tobacco,5 ExxonMobil,6 and BP.7 Monbiot notes that several in or close to the current government, including the prime minister's chief economic advisor, were previously employed in these thinktanks.48

The logic for the powerful to support these thinktanks is inescapable. Relatively small sums of money can yield valuable returns if the ideas they promote change minds, or shift the window of possible policy options. Often this involves capturing the dominant narrative, for example by portraying evidence as complex or contested, and evidence-based regulation as overbearing or “nanny-state.” Tobacco companies invested large amounts in funding science to mislead the public on the causes of lung cancer,9 while the fossil fuel industry paid for advertorials questioning the science on climate change.10 The issues may vary but the approaches are similar, embracing outright denialism and scepticism and typically shifting the burden of responsibility from corporations to individuals.1112 All too often, a change in legislation delivers the power and influence that the funders seek to safeguard their interests, at the expense of wider society.13 Collectively, these phenomena are now the subject of study as the commercial determinants of health.14 They contributed substantially to the inequality that left the UK so vulnerable to the effects of the pandemic,1516 to the worst aspects of the covid-19 response, with procurement failures and price-gouging,1718 and the current energy crisis, with profiteering characterised by the UN Secretary General in August 2022 as “immoral,”19 and now, they influence our economic future and physical environment, and through it, the future of health inequalities in the UK.

The US journalist Jane Mayer noted a similar pattern in her forensic analysis of the effects of corporate funders in her book “Dark Money.”20 In 2011, when 24 million Americans were out of work in the wake of the financial crisis, advancing the agenda of the wealthiest Americans seemed like an impossibility. Yet, she writes that ”…after 40 years, the conservative nonprofit ecosystem had grown quite adept at waging battles of ideas. The think tanks, advocacy groups, and talking heads on the right sprang into action, shaping a political narrative that staved off the kind of course correction that might otherwise have been expected.”20 There is no question the UK finds itself in a time of crisis, with worsening health,21 a struggling health service,22 an economic recession,23 rising cost of living,24 a diminishing workforce,25 and the aftermath of the pandemic.26 There is no doubt that bold action is needed, both now, and to “build back better” in future. But building back better starts with knowing what is broken.27

The oft quoted Virchow famously wrote: “Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution.” In other words, we bear the responsibility for shining a light on the forces that shape society, in ways that can inform decision-making. In judging the potential utility of a medicine, we demand transparency from its makers and from decision-making bodies. Somehow, we have drifted from this principle when it comes to medicine on the larger scale, but there is no question we must increasingly interrogate the political and commercial determinants of health.

If we were facing an instance of environmental contamination, then we would expect not only to bear witness to the effects on those exposed, but also the source of the contamination so that it might be halted. Population health is fundamentally shaped by political decisions28 and commercial power, and the principle remains the same.

In a time of profound economic upheaval, when seemingly inexplicable risks are being taken with public finances, we as health researchers share a responsibility to bear witness to the upstream forces shaping the health of our societies. If we wish to produce the evidence on possible ways forward, we need to also acknowledge the pollution of our discourse.29 If we truly wish to be patient-centred, to care about the most marginalised in society, we must bear witness to the forces that keep them so marginalised, that erode regulation and the functioning of government.

Be it in the context of this mini-budget, covid-19, or the climate crisis, we are in the era of the commercial determinants of health. The question is, will we rise to the challenge?