As digital systems increasingly shape everyday life, public health must look beyond access and services to address how online environments influence health choices and outcomes
Since the World Health Organization’s first resolution on the internet and health in 1998, digital health policy has wrestled with commercial influence online, but largely focused on health systems, records, interoperability and standards. In 2025, the World Health Assembly took up the digital marketing of infant formula, after research found that formula brands reach three times as many people online as posts about breastfeeding. Marketing does more than deliver information. It shapes how people feel about their health and what they aspire to. Social media feeds, group chats and marketplaces are part of everyday life alongside the health clinic, the shop and the family. In all of them, people work out what a healthy body, a good birth or a good parent looks like, what is a health risk and what to want for their own health. Prevention now starts in those settings.
Living on someone else’s terms
Cesar Victora wrote that new health technologies reach the most advantaged first. Across 70 low- and middle-income countries he found a mobile phone in 87% of households, and in the hands of 56% of mothers. A woman without a phone still lives in a community that has been transformed by phones. She hears what her family, neighbours and friends have seen, the local shop stocks what sells online, and her health worker uses the same platforms. Digital inequity used to mean not being digitally connected. It now also means living in settings other people design, connected or not.
Digital is not neutral
Sara Davis has argued that the tools guiding national digital health strategies do not prompt governments to consider the broader political and information environment in which people use technology for health. That leaves out who runs the settings where people form what they want for their own health, who profits from them and who pays for the harms. Current global strategies define digital determinants largely through access, literacy and the use of digital health services. Neither this framing nor its definition of equity addresses the digital settings where people already spend their lives. What a health-promoting digital environment would look like has still to be described.
Health promotion defines equity as the conditions people live in. The Ottawa Charter made acting on those conditions a health responsibility across sectors such as housing, transport, food and work. Supportive environments once meant safe schools, healthy workplaces and clean neighbourhoods. They now also need to mean the commercialised digital settings that shape health norms and what people come to want for their own health and well-being.
Digital settings for health
Public health has long worked on designing health-promoting environments. Roads are built to a specification, and initially that specification was mostly about vehicle speed, until public health drew attention to the people crossing them. The role of public health has been to shape roads so the setting supports the people in it. A road is one road, however differently people use it, and its specification is published. A digital setting is built to a specification that differs for each person, is not published, and is rewritten daily to hold attention and turn it into sales. Governments set rules for these settings through artificial intelligence and industrial policy, and health systems inherit the conditions and the costs.
Governments can do three things, each adapting a health promotion method for digital futures.
Write down what a health-promoting digital environment looks like, once, instead of adding digital to one product at a time. Since the code on breast milk substitutes was adopted in 1981, 144 countries have adopted legal measures on it, but only 37 mention the internet. Alcohol, supplements and wellness products are still waiting.
Assess what the digital transformation of society is doing to health: the norms it shifts, the products and fraud sold to people, and what they come to expect of their own health. The Ottawa Charter asked for this in 1986, naming technology among the areas of rapid change, and said the assessment must be followed by action. Health impact assessment has been used on air pollution, urban transport and development projects, but not yet on a digital environment.
Give the health sector a defined role when digital, telecom, advertising and consumer rules are written, and the lead where health is the subject. Manage commercial influence over the rules themselves, using the conflict-of-interest instruments health already has. A conflict-of-interest test asks what a company’s services do to health, and harm in one part of a business cannot be offset by benefit in another.
Digital transformation is changing the conditions in which health is made, faster than they are being described. If public health does not help shape health-promoting digital environments, harms to health and well-being will go on being monetised.
