No silver bullet: Contending with the commercial determinants of health and overmedicalisation

We live our lives surrounded by forces that promote or degrade health and wellbeing. As social beings, humans are influenced by interactions with all sorts of entities from the minute—think microbes—to the mammoth—think corporations and industries. Many of those forces that affect health are familiar to us as nurses. Working to address them most often feels at least partly in our control. Pathogenic microbes are a good example here. We know what to do or quickly when it comes to pathogens. So too do we now have some responses in our repetoire to address other entities now commonplace in our daily lives. Think of social media, for instance, and the extent to which some of us are now studying the use of smartwatches as a tool to support older person's function and safety. In contrast, corporations are a less familiar factor in our perspective on health and wellbeing. We do, however, frequently consider the health implications of many commercial products as with my example of studying smartwatches as a tool for health. But expanding our thinking to understand that corporations and not just their products frequently influence health can be perplexing. Thinking of corporations as affecting our health might come as a surprise to some. The ‘aha’ moment arrives as we reflect on the definition of a framework called the commercial determinants of health (CDOH) (Gilmore et al., 2023). The CDOH are those forces emerging from the private economic sector that influence health and wellbeing. Everyday examples include the processed food and the automobile industries. First emerging in the international health literature more than a decade ago, CDOH are recognised by the World Health Organization (WHO) (https://www.who.int/news-room/fact-sheets/detail/commercial-determinants-of-health). Akin to the social determinants of health (SDOH), CDOH is a framework explicitly aimed at explicating the influence of the private economic sector on population health. Like the SDOH, CDOH poses critical questions about justice and equity in health, wellbeing, and care to support ensure these states. The WHO importantly and carefully outlines how CDOH generate both positive and negative impact on the health of various populations around the world. Examples of CDOH with negative effects come more easily to mind than those creating positive impact. Consider the automobile industry, one on which modern life relies for huge numbers of people around the world. The incredibly positive advent of seatbelts and infant safety seats now mitigates injuries resulting from road traffic accidents in many places around the world. Conversely, negative impacts include direct and indirect carbon emissions from automobile assembly plants and use of petroleum as fuel for most vehicles. The CDOH are among contemporary conceptual frames available to understand variations in health and wellbeing of people and populations around the world. Surprisingly, given the widespread use of SDOH in our discipline, CDOH have yet to enter the wider nursing lexicon or to substantively influence development of our science, education, and practice. But this conceptual frame should most certainly be part of nursing. The extent to which CDOH shapes our practice as nurses and specifically as gerontological nurses is difficult to overestimate. The fossil fuel industry is among the most familiar examples offered in discussing CDOH. The effects of greenhouse gas emissions from petroleum products that contribute broadly to the planetary crisis and specifically to global heating contributes to injuries from extreme heat, dementia and acute and chronic lung disease among many other conditions. As nurses, we have long investigated means to improve symptoms, health experiences, self-care and self-management among older people living with these conditions. How often, however, do we study the extent to which a CDOH is at play and how we might modify or remove that influence? Not as often as we might were we to broaden our vision and expand our scope to include CDOH. Our science, education and practice exist in extraordinarily complex sociocultural and sociopolitical landscapes around the world. Local context is then key to what we do as nurses. We conduct research, educate the public and our students, and provide care within societally specific healthcare systems and wider cultures. The COVID pandemic, with its rapid spread and repeated waves of infection underscored that those systems and cultures exist in a larger, highly interconnected global context where factors like vector-borne illnesses and environmental changes know no boundaries. The far-reaching effects of the fossil fuel industry is a prime example of a CDOH that sits at both local and national levels—through corporations, laws, and utilisation—and at international levels with our heating climate as the result. But many CDOH effects are more insidious and continue to elude our viewpoint as nurses. Older person are dominant healthcare consumers in most societies, using services across the healthcare spectrum at levels typically higher than most younger groups. Yet mounting evidence points to the reality that a sizable proportion of healthcare is risky and ineffective along with being personally and financially costly to older people. Overmedicalisation, a concept that may also escape our attention, captures some elements of the risk, harm, and cost entailed here. Like the CDOH, overmedicalisation has been discussed in the global health sciences literature for more than a decade. The BMJ's Too Much Medicine Initiative (https://www.bmj.com/too-much-medicine) from several years ago illustrates some of the highest profile aspects of this phenomenon. Overmedicalisation of maternal-child healthcare is increasingly well studied. Consideration of the effects of overmedicalisation on older people, however, proves elusive. Just why overmedicalisation is not prioritised in care for older people is, like application of SDOH and CDOH, is a complicated question. The structural ageism of healthcare certainly accounts for some neglect of the overmedicalisation experienced by older person. But the true extent to which overmedicalisation is ignored rests in the level of attention accorded CDOH. Healthcare is an industry like any other, one that is attached to others like pharmaceutical, fossil fuel, and even the processed food industries. Most directly, overmedicalisation helps classify negative effects of healthcare as CDOH. Despite growing recognition of overmedicalisation and its perils, healthcare is rarely listed among CDOH. Many may bridle at the thought of healthcare as having anything other than a positive effect on health. Yet extant evidence offers a stark counterpoint. The International Journal of Older People Nursing (IJOPN) Editorial Team which I lead already noted earlier this year (Baumbusch et al., 2023) that many nurses remain unaware that our industry emits notably high levels of greenhouse gases. The global contribution of healthcare greenhouse emissions is about 5% globally and closer to 10% here in the United States where I live (Lenzen et al., 2020). These emissions and other impacts on the planet and our climate effectively illustrate how healthcare is indeed a CDOH. Other examples with direct bearing on care for older people are easy to uncover. Consider polypharmacy and all its attendant risks as another illustration of how healthcare is a CDOH with negative effects on older people. Polypharmacy also illustrates how, just as in the climate crisis, this CDOH has both direct and indirect impact that involves other industries. Polypharmacy has both direct effects like toxicities that alter organ function and indirect effects like side effects or interactions that cause events that may be repetitive or delayed like falls. Medication overuse and use of potentially inappropriate medications (2019 American Geriatrics Society Beers Criteria® Update Expert Panel, 2019) implicates both the healthcare and pharmaceutical industries. Other, less obvious negative CDOH in healthcare are not too difficult to find. Think of the now commonplace overreliance on commercially prepared nutritional supplements in care for older people. Those supplements are processed and may be ultra-processed with attendant health effects that counter their potential to improve the nutrition and wellbeing of older people. Moreover, the carbon footprint of these products may be intensive owing, for example, to manufacturing and transportation. Such supplements may be the best option to support good nutrition for some. Nonetheless, they are not a sustainable solution commensurate with optimal nutrition, enjoyment in eating, and food security at a population-level across our ageing societies. The widespread availability and reliance on disposable incontinence garments are likewise can be viewed as a negative CDOH where both the healthcare and personal products industries are at play. Again, while use of these products is the only viable option for some, the scarcity of continence care from qualified nurses and the environmental effects of using both disposable and washable incontinence containment products highlights both risks and harms that using these products generates. The web of interconnections among healthcare, the planetary crisis and global heating, CDOH, and SDOH are always present. They shape our lives and our profession whether we acknowledge these forces directly or not. This web of direct, indirect, positive, and negative influences underscores the value and primacy of health as we conceptualise it in nursing. Our work as nurses with individuals, families, and communities is salutogenic—or health promoting. We see people in the context of their relationships and their local and global environments. Further, we nurses believe that health and wellbeing must be equitably and justly distributed across populations and the lifespan to assure health for all. Ensuring our research, practice and education support health and wellbeing in just and equitable ways then obligates us to be mindful of the interconnections between and among healthcare, the planetary crisis, CDOH, and SDOH. Thus, we must map our current and future research, practice, and education to CDOH, SDOH, and the planetary crisis. But the thought of ‘what can we as nurses really do to alter these calamities?’ may threaten to overwhelm us. The answer to the question of ‘what can we nurses can do?’ is plenty but every opportunity is moulded by the complex and nuanced nature of the issues at hand. Opportunities exist at many levels across our specialty and more broadly in nursing and our communities. Discovering and capitalising on those opportunities requires, though, that we dismantle the adherent structural discrimination. Ageism, healthism, ableism and other forms of social discrimination augment and advance negative effects of CDOH as they do those of SDOH. Consider the broad acceptance of incontinence among older people as an instance of structural ageism that then promotes use of incontinence containment products and medications when evidence points to behavioural therapies as first-line choices for treatment. Consequently, our actions in research, education and practice must be inherently anti-discriminatory to succeed. Dismantling discrimination then empowers us, older people, and other partners to design, test, implement and evaluate solutions in opportunities we discover. For example, a nurse-pharmacist partnership for deprescribing could curtail polypharmacy and help address overmedicalisation. Collaborating with cooks, dietitians and farmers might result in what Healthcare Without Harm outlines as a plant-forward diet (https://noharm-uscanada.org/issues/us-canada/people-and-planet-friendly-food). Such a collaboration could make for a culturally attuned, plant forward diet with meals and snacks that meet the needs and desires of, for instance, older people living in a long-term care setting. That diet would simultaneously limit reliance on processed and ultra-processed foods, benefiting the health of those people and the planet. Connecting with gardeners could bring horticultural therapy into healthcare settings or the homes of older people unable get outside by themselves, offering them the advantages of connecting with both plants and people. Similarly, creating a team of colleagues committed to promoting exercise among older people could result in a program to target continence, chronic pain, or mood and affect, or in deed all three domains. The possibilities for exploration, change and evaluation are limitless. We invite authors to consider IJOPN as the place for their manuscripts reporting research and evidence syntheses that address aspects of the planetary crisis, CDOH, and SDOH relevant to gerontological nursing and the health and wellbeing of older people. Reports of community-based participatory and action projects are especially welcome. Evidence syntheses called ‘empty reviews’ are also welcome as critical commentaries on the influence of phenomena like CDOH and overmedicalisation in gerontological nursing and care for older people. As always, my colleagues and I will gladly answer all author queries about manuscripts via email or on social media though query letters are not required or necessary for most manuscripts. Authors, reviewers and readers can find us on Facebook at https://www.facebook.com/IJOPN/ and on Twitter with the handle @IntJnlOPN (https://twitter.com/intjnlopn?lang=en). We look forward to hearing from you! The author has no conflicting or competing interests to declare. No data were used.

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