What's in a name? A call to reframe non-communicable diseases
Authors: Luke N Allen, Andrea B Feigl
Journal: The Lancet Global Health (2017)

The global health community does not spend much time on branding, which perhaps explains why existing classifications for the three largest groups of diseases are both outdated and counterproductive. The first Global Burden of Disease study1Murray CJ Lopez AD Jamison DT The global burden of disease in 1990: summary results, sensitivity analysis and future directions.Bull World Health Organ. 1994; 72: 495-509PubMed Google Scholar described infectious diseases, non-communicable diseases (NCDs), and injuries. This grouping reflected a predominantly infectious disease burden in low-income and middle-income countries, which has since tilted towards NCDs. A name that is a longwinded non-definition, and that only tells us what this group of diseases is not, is not befitting of a group of diseases that now constitute the world's largest killer. NCDs—which include cancer, diabetes, chronic obstructive pulmonary disease, cardiovascular disease, and mental health conditions—are the leading cause of death worldwide2WHOGlobal status report on noncommunicable diseases 2010. World Health Organization, Geneva2011Google Scholar and disproportionately afflict developing countries (unpublished). NCDs will cost the global economy US$47 trillion over the next two decades, and they continue to push millions of people into poverty.3Bloom DE Chisholm D Jane-Llopis E Prettner K Stein A Feigl A From burden to best buys: reducing the economic impact of non-communicable diseases in low- and middle-income countries. World Economic Forum, Geneva2011Google Scholar Nevertheless, NCDs receive the lowest overseas development assistance per disability-adjusted life-year, and even the most cost-effective NCD interventions are severely underfunded compared with their infectious disease counterparts.4Allen L Non-communicable disease funding.Lancet Diabetes Endocrinol. 2016; (published online December 18.)http://dx.doi.org/10.1016/S2213-8587(16)30420-XGoogle Scholar What's more, NCDs are under-represented in developing countries' national health plans, undermining progress towards reaching universal health coverage and improvement of human capital.5Sridhar D Batniji R Misfinancing global health: a case for transparency in disbursements and decision making.Lancet. 2008; 372: 1185-1191Summary Full Text Full Text PDF PubMed Scopus (159) Google Scholar NCDs share all the ideological and social justice issues of HIV but cause 30 times more deaths and receive 17 times less funding.6Murray CJ Anderson B Burstein R et al.Development assistance for health: trends and prospects.Lancet. 2011; 378: 8-10Summary Full Text Full Text PDF PubMed Scopus (72) Google Scholar The disproportionately low levels of national and international attention paid to NCDs in terms of action plans, funding, and global institutions might be partly attributable to the framing of these conditions. After all, "anything that begins with 'non' may be considered a 'non-issue' or a 'non-starter'".7Sridhar D Morrison JS Piot P Getting the politics right for the September 2011 UN High-Level Meeting on Noncommunicable Diseases. Center for Strategic and International Studies, Washington, DC2011Google Scholar Evidence is mounting that some NCDs are partly or wholly communicable. They can be spread through social networks,8Christakis NA Fowler JH Social contagion theory: examining dynamic social networks and human behavior.Stat Med. 2013; 32: 556-577Crossref PubMed Scopus (653) Google Scholar viruses such as hepatitis and human papillomavirus, the built environment,9Hipp JA Chalise N Spatial analysis and correlates of county-level diabetes prevalence, 2009–2010.Prev Chronic Dis. 2015; 12: E08Google Scholar cultural and economic conditions, food deserts (ie, areas short on fresh fruit, vegetables, and other healthy foods),10Ferdinand AO Sen B Rahurkar S Engler S Menachemi N The relationship between built environments and physical activity: a systematic review.Am J Public Health. 2012; 102: e7-13Crossref PubMed Scopus (211) Google Scholar and intergenerational transmission (ie, diabetes and obesity). Furthermore, the present misnomer implies that the causes are individual rather than societal. This implication is simply not the case: NCDs have largely sociogenetic antecedents, and efforts focused on individual behaviour have little overall effect if the social and policy environments do not change in parallel. The ongoing and largely unhelpful emphasis on individual healthy choices might hamper a shift towards more effective and equitable population-level policies such as tighter tobacco control and measures to address obesogenic environments. Unfortunately, system-wide socioeconomic drivers are difficult to change and do not have the political expediency of blaming poor people for making poor decisions. Additionally, regulatory changes in tobacco, alcohol, and food policy can face stiff opposition from powerful economic interests. Calling the world's biggest killer "non-communicable" propagates confusion, undermines efforts to spur a sense of urgency, and deflects attention from effective system-wide interventions. There have been repeated calls to rename NCDs and a widespread acceptance that the term is a poor fit, but the lack of convincing alternatives and inertia stemming from widespread use seem unsurmountable. Renaming NCDs is not an issue of pedantry; it is an important means of consolidating the growing support for these ubiquitous conditions and invigorating the debate around interventions that stand the best chance of stemming the pandemic. The Sustainable Development Goals (SDGs) have cemented the importance of NCDs on the international agenda, and over the next few months the global health community will choose appropriate indicators for Goal 3. Now is the perfect time to refocus the global response through reframing the issue. Unless this long-debated issue of naming is comprehensively addressed, it will regularly resurface and might stand in the way of real progress. Although we are certain that the name NCD needs to go, we do not have a perfect alternative. We favour the terms societal and ecological (ie, the relation of living organisms to one another and to their physical surroundings) but hereby invite debate on the topic under the auspices of The Lancet Global Health. Online, public, global forums—akin to the global dialogue of the Global Coordinating Mechanism on the Prevention and Control of NCDs and the 2 month online debate that followed, or the SDG indicator consultation—are setting new norms of transparency and inclusion of multiple stakeholders in important decision-making processes. What should this group of conditions be called? Should the lines be redrawn to include injuries? Is chronic a synonym? Are social injustice, globalisation, or socioeconomic transitions causative pathogens? Overall, this global consultative process should include not only the submission of new names but also a substantive discussion on the specific diseases and risks addressed. The new classification could be institutionalised in the next version of the System of Health Accounts and the Organisation for Economic Co-operation and Development's Development Assistance Committee system (soon to include line items specific to chronic diseases), and potentially adopted by WHO in 2020, after the Global Action Plan for NCDs expires. We believe that this process has the potential to foster innovation, multisectoral action, and increased funding for the conditions that kill 38 million people each year. We declare no competing interests. The content of the publication does not necessarily represent the view of the OECD or of its member countries. We contributed equally to this Comment. We thank David E Bloom (Harvard T H Chan School of Public Health, Boston, MA, USA) for his input and contributions to earlier drafts of this Comment. Reframing non-communicable diseases – Authors' replyLavanya Vijayasingham and Pascale Allotey suggest a conceptual extension of the socially transmitted condition (STC) framework to emphasise the role of social factors not only in predisposing individuals to the development of these diseases, but also in shaping the disease course and lived experience. Their reasoning is borne by evidence that socioeconomic factors correlate with STC behavioural risk factors,1 prevalence rates,2 and risk of premature death.3 Full-Text PDF Open AccessRenaming non-communicable diseasesLuke Allen and Andrea Feigl issue an impassioned call to reframe non-communicable diseases (NCDs).1 They argue that "non-communicable" insinuates "less important" relative to infectious diseases, producing a dearth of NCD attention and funding. Granting a priori precedence to infectious diseases as the primary concerns for mortality and biosecurity risks undermining broader collaborative contributions aimed at promoting health equity. 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 AccessRenaming non-communicable diseasesThe call by Luke Allen and Andrea Feigl (February, 2017)1 to reframe non-communicable diseases (NCDs) is welcome. The lack of focus on these increasingly important causes of morbidity, impairment, and mortality, with their commensurate increasing consumption of health and societal resources and reduced economic contribution, is inappropriate and damaging for all the reasons Allen and Feigl cogently argue. Few things that are described in the negative as what they are not obtain the understanding or action they deserve. Full-Text PDF Open AccessRenaming non-communicable diseasesThe debate opened up through the Comment by Luke Allen and Andrea Feigl1 is timely and welcomed. The framing of non-communicable diseases (NCDs) has been an ongoing challenge for those working on prevention and one that has not been fully addressed or resolved. Full-Text PDF Open AccessRenaming non-communicable diseasesReframing non-communicable diseases (NCDs) to "spur a sense of urgency" and "focus attention on effective system-wide interventions"1 makes sense. With almost three-quarters of NCD deaths now occurring in low-income and middle-income countries (LMICs), the increasing burden of NCDs already has severe economic consequences that impoverish families, jeopardise health systems, and hinder social and economic development.2 Full-Text PDF Open Access