Reframing non-communicable diseases as socially transmitted conditions

In a Comment (February, 2017),1Allen L Feigl A What's in a name? A call to reframe non-communicable diseases.Lancet Glob Health. 2017; 2: e129-e130Summary Full Text Full Text PDF Scopus (42) Google Scholar we argued that action on the conditions currently referred to as non-communicable diseases (NCDs) may be hampered by the inadequacy of their label. We received a remarkable amount of feedback on this suggestion, and in this Comment we synthesise the responses garnered from a Lancet Facebook poll, Correspondence letters,2Rigby M Renaming non-communicable diseases.Lancet Glob Health. 2017; 5: e653Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 3Lincoln P Renaming non-communicable diseases.Lancet Glob Health. 2017; 5: e654Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 4Kozelka EE Jenkins JH Renaming non-communicable diseases.Lancet Glob Health. 2017; 5: e655Summary Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 5Zou G Decoster K McPake B Witter S Renaming non-communicable diseases.Lancet Glob Health. 2017; 5: e656Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar and a related GHD Online discussion. We also propose a new definition based on shared social drivers. The majority of respondents (29 of 47) to the Facebook poll thought that the NCD name should indeed be changed, and almost everyone acknowledged the limitations of the current label. Many NCDs are in fact communicable, and the current anti-definition provides no information about what unites these conditions. This makes it hard for politicians and the general public to grasp the main challenges posed by NCDs: a problem that is exacerbated by the implication that individual (rather than societal) factors are the key determinants. The current misnomer is misleading but not completely useless: it has currency within the global health community and multiple donors, government departments, non-governmental organisations, and academic units use NCD in their own names and programme titles. Then there is the fact that the name itself does not matter at all, as long as the conditions and their drivers are being addressed. Unfortunately our efforts to prevent and control NCDs have been underfunded, misdirected, and underwhelming to date.6Nugent R Feigl A Where have all the donors gone?.in: Scarce donor funding for non-communicable diseases. World Health Organization, Geneva2015Google Scholar Most governments focus on individual lifestyle choices, and only a minority of developing countries have implemented WHO “best buys” such as tobacco taxation, salt reduction, and elimination of trans fats.7World Health Organization, World Economic ForumFrom burden to “best buys”: reducing the economic impact of NCDs in low- and middle-income countries. World Health Organization, Geneva2011Google Scholar There is a lot to gain by framing NCDs in the context of our contemporary understanding of these conditions. Similarly, there is little to lose by abandoning a term that does not resonate with the evidence or the general public. The majority of suggestions for alternative names (table) either emphasised the chronicity of NCDs or the fact that they are driven by a common set of anthropogenic drivers. The striking heterogeneity speaks to the fact that NCDs mean many different things to different groups. It is also clear that the nondescript nature of the current label permits broad interpretation and recruitment of disparate parties, all flying the same banner but with many different agendas.TableSuggested alternatives to the term “non-communicable disease”, and comments thereonCommentIndustriogenic diseasesBiosocial and developmental diseases[Societally] preventable chronic diseasesSocietal diseasesWealth-related diseasesThese terms highlight the central role of the anthropogenic trends and structures that are driving the pandemic. The preventable nature of NCDs and socioeconomic inequalities are also implied. These definitions exclude a number of existing NCDs where association with social factors is weak—eg, glaucoma, infertility, Parkinson's disease.Terms that emphasise chronicityChronic & lifestyle-related conditionsChronic conditionsChronic syndromeEnfermedades crónicasChronic disability syndromeLong-term diseasesLife-long diseases/learn2liveLife-long progressive conditionsThese suggestions hinge on the fact that NCDs are life-long conditions. Chronicity characterises most of the existing NCDs, but also applies to many infectious diseases like HIV and tuberculosis. With these names the focus is on the disease course at the individual level rather than shared antecedents. The terms are non-stigmatising. They also emphasise the need for long-term investment and prevention of disability and premature mortality.OthersThe major diseasesDefined on the basis of global burden—may change over timeCardiometabolic diseasesCaptures the leading cause of mortality but nothing elseInsidious killer diseasesConveys a sense of urgency but stigmatising to live withProximal disordersFocuses on shared risk factors but is quite an opaque termInteractional diseasesBiosocial framing that stresses political-economic factorsComplex chronic diseases (vs infectious chronic diseases)Infers that complex solutions are required. Adoption would require changing the international classification of diseasesABC (avoidable, behavioural, and chronic) diseasesCatchy term that includes three core characteristics but also applies to infectious diseases—eg, syphilisBlue and greenProbably refers to the IHME visualisation of the global burden of disease, not very clear for the uninitiatedNCDs=non-communicable diseases. IHME=Institute for Health Metrics and Evaluation. Open table in a new tab NCDs=non-communicable diseases. IHME=Institute for Health Metrics and Evaluation. There is no single thread that unites all NCDs and neatly separates them from classical infectious diseases. The current list of NCDs describes a ragtag group of leftovers that do not satisfy Koch's postulates8Koch R Die Atiologic der Tuberkulose.Berliner Klinische Wochenschrift. 1882; 15: 221-230Google Scholar nor fit neatly into other categories. NCDs include congenital conditions (eg, Down's syndrome and neural tube defects), degenerative conditions (prostatic hypertrophy, cataracts, and hearing loss), musculoskeletal problems (back pain, arthritis, gout), genitourinary conditions (infertility and kidney stones), mental health problems (depression, schizophrenia), and the “big four”—cardiovascular disease, cancer, chronic respiratory disease, and type 2 diabetes. Although there is no one core characteristic that unites all of the NCDs, a number of themes run through the current group: •Chronicity: many NCDs develop over time in response to chronic risk factor exposure•Global burden: many of these conditions constitute the leading causes of death and disability•The preventable nature of many NCDs•Common proximal physiological risk factors: cholesterol, blood glucose, hypertension, obesity•Common behavioural risk factors: tobacco, alcohol, physical inactivity, diet, indoor air pollution•Common distal risk factors: economic, social, and environmental factors; urbanisation, globalisation, industrialisation, and poverty; all of which are complex issues requiring multisectoral action•Common issues of injustice and socioeconomic inequalities in the international and intranational distribution of risk factors, morbidity, and mortality We feel that the greatest need is for a reorientation towards addressing the commercial and social determinants of NCDs, and the socioeconomic inequalities within and between countries. We would also like to see more funding for NCDs, commensurate with the global health and economic levies they impose, as well as concerted action toward the structural social and commercial determinants of health. Other disease groupings have been defined on the basis of shared pathogenesis (eg, cancers), the systems they affect (eg, respiratory diseases), when they occur in the life course (neonatal and maternal conditions), and common behavioural antecedents (eg, sexually transmitted infections). We feel it is most appropriate to bind NCDs together using their common upstream drivers. We therefore propose the new term “socially transmitted conditions” (STCs). This label stresses the anthropogenic and socially contagious nature of the diseases: STCs are driven by urbanisation, industrialisation, and poverty, the availability of tobacco, alcohol, and processed foods, and physical inactivity. STCs also share a common set of solutions focused on addressing the complex and often unjust structure of society. It is important not to absolve individuals of all responsibility for their own health and lifestyle choices, while highlighting the fact that our changing social environment strongly influences the set of choices available. The term “socially transmitted” shifts the implied locus of action upstream. The term also provides clarity by describing the core uniting characteristic of the disease group. Virtually all diseases are influenced by social factors to some degree, and we stress that STCs are distinguished by the common constellation of social drivers that they share. We also note that congenital and degenerative conditions are imperfectly captured by our new name. This is a pertinent issue for future discussion, since the current NCD response also tends to overlook these diseases (viz the 2011 UN High Level Meeting semantics9United Nations General AssemblyPolitical Declaration of the UN High Level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. 24 January 2012Google Scholar and the WHO best buy interventions7World Health Organization, World Economic ForumFrom burden to “best buys”: reducing the economic impact of NCDs in low- and middle-income countries. World Health Organization, Geneva2011Google Scholar). Despite these limitations, the preface “socially transmitted” is vastly more transparent, accurate, and tractable than “non-communicable”. Importantly, it also challenges the persisting misconception that individual greed and sloth are driving the global epidemiological transition. The recent move from “international health” to “global health” demonstrates that a name change can helpfully galvanise the reconceptualization of an entire field. The responses to our initial article demonstrated that no-one has a very good grasp of what NCDs actually are in the first place. By proposing a coherent and internationally significant narrative we hope to stimulate greater action on the major drivers of the world's most important conditions. We declare no competing interests. The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries. Palliative care and the endless cycle of serious health-related sufferingAs Richard Horton pointed out (April 14, p 1465),1 obstacles to accessing palliative care affecting those living with serious health-related suffering are, without any doubt, “the most disfiguring inequity in health care today”. Full-Text PDF Reframing non-communicable diseasesIn reframing non-communicable diseases (NCDs) as socially transmitted conditions bound by common upstream drivers, Luke Allen and Andrea Feigl (July, 2017),1 suggest a strong focus on the causative aspects of social context. We suggest a conceptual extension: if social factors drive the prevalence of these conditions, then social factors drive their lived consequences and course. Full-Text PDF Open AccessReframing non-communicable diseasesThe collective dynamic initiated by Luke Allen and Andrea Feigl1 is remarkable, and explains why they felt the need to formulate a new proposal,2 which involves renaming and reframing non-communicable diseases (NCDs) as socially transmitted conditions (STCs). Full-Text PDF Open Access