The Qatar World Cup and the commercial determinants of health

The events leading up to the Qatar World Cup showed the dark side of a beautiful game, but they also provide a window into the forces that shape health.

In recent weeks, I have been glued to my phone watching the World Cup, sometimes I must admit surreptitiously during Zoom meetings. In this, I have been far from alone. The World Cup is, in terms of audience, by a fair measure the world’s largest global sporting event. In 2018, over half the world’s population watched the competition. The World Cup is always exciting, both for the competition itself and for the human stories of its participants. The contenders include preening superstars (Ronaldo…) and young upstarts, national clubs that are well-oiled winning machines and scrappy underdogs looking to earn an upset for the ages. It will be a while before we forget Morocco shocking Spain this week, with the former world champions heading home while Morocco moves forward.

But the World Cup has other stories as well. The narrative leading up to this year’s competition includes much that is unprecedented. It is being held in winter in Qatar—the first time the World Cup has been in the Middle East—as to hold it in its traditional time of summer would be too hot for the players. Then there are the horrific stories about the lives of migrant workers lost due to the conditions many of them experienced in building the stadiums where the games are happening. During the lead-up to the World Cup, reports of this abuse as well as bribery and corruption of officials involved in bringing the games to Qatar, and the broader issue of human rights violations within the country, have complicated the joy soccer fans take in the World Cup. It has, rightly, prompted the question: should we really be holding games in a place where human rights are not respected?

Many have defended Qatar against the opprobrium it has faced, while claiming—not without justification—hypocrisy on the part of a western world that has many human rights issues of its own. Given the fact that many countries have, in their past or present, participated in some form of injustice, a litmus test along these lines would leave the pool of potential hosts quite small. For example, the 2026 World Cup will be held in North America, home to countries which have committed deep wrongs against indigenous populations, which have accepted—until fairly recently in historical terms—slavery, and which now preside over a carceral state that imprisons millions. This record should give us pause and make us think about the ways our house remains in disorder even as we take others to task. As to the corruption of the World Cup selection process: nary a World Cup goes by without some financial shenanigans and allegations of officials behaving in ways that are less than honorable. This is not to condone such practices, only to say that, in criticizing Qatar, the case could be made that we are singling them out for something in which many in global soccer have participated.

How, then, should we think about the World Cup? It strikes me that the competition works best as an example of forces not necessarily unique to Qatar or FIFA, but that in fact reflect the broader function of commercial forces in the world. Global soccer is a business, generating astronomical sums of money. The influence of soccer on global conditions reflects the influence wielded by any commercial actor operating on a similar scale. In this sense, it represents the heart of commercial determinants of health (CDOH) thinking. The CDOH are the private sector actions that influence the conditions that shape health. These conditions include politics, the economy, the physical and social environments in which we live, the data ecosystems that inform science and public policy, and global patterns of trade. Private companies have tremendous sway over these conditions. They influence key areas like the safety of products, the price of goods, worker wages, the flow of energy and information, and the overall health of the economy. This influence is mediated by the choices made by those in positions of corporate leadership. When these choices align with the common good, they can do much to shape a healthier world. When they do not, they can undermine progress.

Fundamentally, a CDOH framework can help us see how commercial forces influence health. There is a temptation in public health to see this influence as always immoral, villainous, given the role of many industries—such as smoking, firearms, and fossil fuels—in undermining health. It is true, many of these industries have caused, and continue to cause, real harm, just as this year’s World Cup has. However, a commercial determinants framework can help us to look deeper and see how this influence is often better characterized as amoral, rather than deliberately malign, and is subject to interests and incentives which can, in many (but not all) cases, be leveraged in a better direction, towards health. The World Cup is an example of this. There is much that has gone wrong with this world cup, but, viewed through a CDOH framework, we can better understand why. By better recognizing the structures that steer commercial forces, we can see how we can influence these forces in the future to support healthier populations. In the case of the World Cup, I would suggest that five key mechanisms are at play.

Political practices

The World Cup is deeply shaped by the politics leading up to it. It would not have been in Qatar without the lobbying and money that are the lifeblood of politics. I have long argued that money and political power are foundational determinants of health, and this remains true in the case of the CDOH. We see it everywhere from the firearm industry’s lobbying against gun reform to the fossil fuel industry’s engagement with the regulatory process. Recognizing the political realities of this influence can help public health better work within the political system to shape corporate practices that support healthy populations.    

Preference shaping

Companies care about their image. They care because they are run by people who share our common human desire to be liked, and they care because a positive perception helps keep conditions favorable for doing business and accessing the broadest possible market. Bringing the World Cup to Qatar was, in large part, about improving perceptions of the country. Perhaps ironically, it seems to have done the opposite, shining a global spotlight on how Qatar abuses human rights. Nevertheless, the pursuit of preference-shaping remains a key force driving commercial decisions, and, for this reason, represents an opportunity for public health. A company that meaningfully supports health is a company that looks good; this can be a powerful incentive for aligning corporate practices with our mission.

Knowledge environment

The battle over how much harm this year’s World Cup has caused has been waged over facts, figures, and the interpretation of data. This is an area that is uniquely subject to manipulation. Corporations making harmful products have long sought to shape the knowledge environment to their advantage. For example, the smoking industry engaged in misleading public-facing communications about cigarettes, using marketing to imply smoking had health benefits and downplaying research showing that, in fact, the contrary was true. In our recent study, we analyzed how firearm manufacturers communicate to the public about gun violence. We found firearm manufacturers tend to frame the challenge of gun violence in a manner consistent with how other makers of dangerous products address the harms their products cause. This includes disputing evidence of the death and injury caused by guns and emphasizing the role of individual responsibility, rather than the culpability of guns themselves, in causing injury and death. These practices echo disputes over just how bad the behavior of Qatar and FIFA has been and reflect the importance of the knowledge environment to our understanding of the CDOH.

Legal environment      

Companies have long engaged with the legal system to create conditions favorable to the continued generation of profit. They have resisted fair labor laws, pursued tax breaks and loopholes, and used the law to fight critics. In Qatar, the legal system has intersected with its violation of human rights during the World Cup, notably in its anti-LGBTQ policies. In a country where LGBTQ populations can face prison time, fans and teams were told they could not wear paraphernalia supporting LGBTQ rights. The leveraging of the legal environment towards the goals of corporate and political power are core to a realistic understanding of the incentive structure that shapes the CDOH and are a key area for engagement if we are to create incentives that generate health.      

Extra-legal environment

The World Cup is, in many ways, the classic extra-legal environment, friendly to the practice of “sportswashing” in which countries or other entities guilty of human rights violations use sports to effectively launder their reputations on the international stage. The glamor of sports, the goodwill and passion of fans, and the global coming-together created by international competitions are powerful tools for distracting from failures to support health and human rights. When companies aim to distract from such failures, it is important to call them out on it, with the understanding that we cannot address such challenges if our collective gaze is directed elsewhere.

A CDOH framework can help us to better understand these mechanisms, evaluate the harms they can reflect, and maximize the benefits of a corporate incentive structure that is aligned with health. These are the goals of the new book I have co-edited with Nason Maani, and Mark Petticrew, The Commercial Determinants of Health, from Oxford University Press. It is the first book to examine the CDOH as a distinct focus area for research, activism, and policymaking. The book features case studies in key sectors and brings together perspectives from fields that intersect with the commercial determinants of health, from economics to public policy. We much appreciate the many experts who contributed to the book, providing insights that greatly broadened its scope.

It is our hope that the book can serve as a framework for our thinking about the CDOH, towards helping advance corporate practices that allow us to enjoy the benefits of what the profit motive can produce and support—like the quadrennial global showcase for the beautiful game—maximizing the good it can do, while minimizing its harms.