Reframing non-communicable diseases
Authors: Catherine Cavalin, Alain Lescoat
Journal: The Lancet Global Health (2017)

The collective dynamic initiated by Luke Allen and Andrea Feigl1Allen LN Feigl AB What's in a name? A call to reframe non-communicable diseases.Lancet. 2017; 5: e129-e130PubMed Scopus (42) Google Scholar is remarkable, and explains why they felt the need to formulate a new proposal,2Allen LN Feigl AB Reframing non-communicable diseases as socially transmitted conditions.Lancet Glob Health. 2017; 5: e644-e646Summary Full Text Full Text PDF PubMed Scopus (46) Google Scholar which involves renaming and reframing non-communicable diseases (NCDs) as socially transmitted conditions (STCs). Allen and Feigl explicitly and implicitly summarise what nomenclatures are, as they have been built and studied for the last three centuries.3Foucault M The order of things. An archaeology of the human sciences. Routledge, New York2002: XXVI-X422Google Scholar They remind us that the purpose of the nosological nomenclature under review—communicable diseases versus NCDs—is a cognitive one: by naming things relevantly, a classification is assigned the task of producing knowledge. Allen and Feigl do not restrict nomenclature to a cognitive initiative. They insist on its strong political implications: a relevant name and framework is more likely to raise funds, and to mobilise researchers and decision makers. These two characteristics of nomenclatures also connect through a third dimension. Naming things helps to frame them by putting them in order.3Foucault M The order of things. An archaeology of the human sciences. Routledge, New York2002: XXVI-X422Google Scholar But if this conceptual reform might entail real-life action (public policies and effective research), this is because the diseases' names have ontological power (consider the ontological breadth of diseases shown by Sontag4Sontag S Illness as metaphor. Vintage Books, New York1979: 85Google Scholar). What can we expect from the proposal to relabel NCDs as STCs if we relate it to the above-mentioned properties of a nosological nomenclature? STCs do not bring about a conceptual revolution in aetiology. They conform to the idea that death, disease, and disability are more and more related to behavioural and environmental factors, which has been described and discussed through the epidemiological transition model5Omran AR The epidemiologic transition: a theory of the epidemiology of population change.Milbank Mem Fund Q. 1971; 49: 509-538Crossref PubMed Scopus (1940) Google Scholar for the past 40 years. Drivers being favoured over causes, we remain in the unchanged multicausal paradigm of disease of the epidemiological transition.6Parascandola M The epidemiologic transition and changing concepts of causation and causal inference.Rev D'histoire Sci. 2011; 64: 243-262Crossref Google Scholar Consequently, the new label (STCs) might make the social dimension much more patent, but it does not introduce it as a brand new variable. Since the end of the 1980s, the field of epidemiology has been stirred by debate about its legitimacy in tackling social issues.7Susser M Susser E Choosing a future for epidemiology: I. Eras and paradigms.Am J Public Health. 1996; 86: 668-673Crossref PubMed Scopus (423) Google Scholar The fact that NCDs were already (theoretically) defined as social, behavioural, or environmental did not prevent epidemiology from neglecting the social sciences. Thus, it is anything but sure that the ontological power of the name STCs can overcome these poorly individualistic research avenues. Additionally, implicitly playing on the ambiguity of the notion of contagion (long studied by the social sciences), Allen and Feigl tend to oppose an infectious communicability to a social transmission (in STCs). This overlooks the fact that it is relevant for heuristic and political purposes to think of communicable diseases as being socially or environmentally driven.8Cavalin C Lescoat A Macchi O Revest M Rosental P-A Jégo P Socioenvironmental factors of communicable and non-communicable diseases.Lancet Glob Health. 2017; 5: e487Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar This fits with the widely experienced reality regarding the implementation of public health policies in so-called traditional societies, as the Ebola virus epidemic illustrated once again. We have been told that thinking of diseases as social constructs is a truism.9Rosenberg CE Disease in history: frames and framers.Milbank Q. 1989; 67: 1-15Crossref PubMed Scopus (95) Google Scholar Nevertheless, in addition to using meaningful expressions such as STCs, we should insist on the social continuum that crosscuts all diseases. Socioenvironmental dimensions are intimately interwoven in all diseases. Understanding them through transdisciplinary research must respond to the huge and still poorly explained fraction of the global burden of disease caused by environmental factors (22% of the global burden, including death and disability),10Prüss-Ustün A Wolf J Corvalán C Bos R Neira M Preventing disease through healthy environments. A global assessment of the burden of disease from environmental risks. World Health Organization, Geneva2016: xxiv-x147http://www.who.int/quantifying_ehimpacts/publications/preventing-disease/en/Google Scholar for the sake of efficiency against social inequalities in health. We declare no competing interests. Our contract grant sponsor is the European Research Council (ERC)/SILICOSIS project, Centre for European Studies, Sciences Po (Paris, France), contract grant number: ERC-2011-ADG_20110406^Project ID: 295817. What's in a name? A call to reframe non-communicable diseasesThe 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 study1 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. Full-Text PDF Open AccessReframing non-communicable diseases as socially transmitted conditionsIn a Comment (February, 2017),1 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,2–5 and a related GHD Online discussion . We also propose a new definition based on shared social drivers. Full-Text PDF Open AccessReframing 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 Access