Reframing non-communicable diseases

In reframing non-communicable diseases (NCDs) as socially transmitted conditions bound by common upstream drivers, Luke Allen and Andrea Feigl (July, 2017), 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. This is not a new idea. Social drivers and contexts influence NCD course, severity, and quality of life. Even congenital and degenerative conditions, which Allen and Feigl suggest are imperfectly captured by the term socially transmitted, are subject to the influences of social context in how they are managed. Clinically similar cases of NCDs translate into different consequences, depending on individual circumstances at the micro, meso, and macro levels of context, where the contrast of disease consequences is especially evident between high-income and lowincome countries. As social consequences, we use the example of the work lives of individuals with NCDs, with a view that these consequences are the interplay of individual, organisational, and sociostructural factors. Consider: the differences in access to medicines and finances that enable individuals with NCDs to manage their condition, and consequently their continued employability; the protective structures that buffer against the cumulative health, economic, and social disadvantage of living with an NCD; and the various sociostructural resources, opportunities, and capabilities needed by an individual with an NCD to be resilient to risk and detriment. The resultant experiences and outcomes reflect the imposition of local social architecture and processes.


Reframing noncommunicable diseases
The collective dynamic initiated by Luke Allen and Andrea Feigl 1 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).
Allen and Feigl explicitly and implicitly summarise what nomenclatures are, as they have been built and studied for the last three centuries. 3hey 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. 3ut 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 Sontag 4 ).
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 model 5 for the past 40 years.Drivers being favoured over causes, we remain in the unchanged multicausal paradigm of disease of the epidemiological transition. 6Consequently, 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. 7The 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. 8his 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. 9Nevertheless, 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), 10 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.