Written by Luke N Allen, Andrea B Feigl

DOI: https://dx.doi.org/10.1016/S2214-109X(17)30001-3

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time on branding, which perhaps explains why existing classifications for the three largest groups of diseases are both outdated and counterproductive.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 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.

disease

Image: sphcm.med.unsw.edu.au

NCDs—which include cancer, diabetes, chronic obstructive pulmonary disease, cardiovascular disease, and mental health conditions—are the leading cause of death worldwide2 and disproportionately afflict developing countries (unpublished).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.3Nevertheless, 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.4 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.5 NCDs share all the ideological and social justice issues of HIV but cause 30 times more deaths and receive 17 times less funding.6

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’”.7 Evidence is mounting that some NCDs are partly or wholly communicable. They can be spread through social networks,8 viruses such as hepatitis and human papillomavirus, the built environment,9 cultural and economic conditions, food deserts (ie, areas short on fresh fruit, vegetables, and other healthy foods),10 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.

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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.

References

  1. Murray, CJ, Lopez, AD, and Jamison, DT. The global burden of disease in 1990: summary results, sensitivity analysis and future directions. Bull World Health Organ. 1994; 72: 495–509
  2. WHO. Global status report on noncommunicable diseases 2010. World Health Organization,Geneva; 2011
  3. Bloom, DE, Chisholm, D, Jane-Llopis, E, Prettner, K, Stein, A, and Feigl, A. From burden to best buys: reducing the economic impact of non-communicable diseases in low- and middle-income countries. World Economic Forum, Geneva; 2011
  4. Allen, L. Non-communicable disease funding. Lancet Diabetes Endocrinol. 2016; (published online December 18.)https://dx.doi.org/10.1016/S2213-8587(16)30420-X.
  5. Sridhar, D and Batniji, R. Misfinancing global health: a case for transparency in disbursements and decision making. Lancet. 2008; 372: 1185–1191
  6. Murray, CJ, Anderson, B, Burstein, R et al. Development assistance for health: trends and prospects. Lancet. 2011; 378: 8–10
  7. Sridhar, D, Morrison, JS, and Piot, P. Getting the politics right for the September 2011 UN High-Level Meeting on Noncommunicable Diseases. Center for Strategic and International Studies,Washington, DC; 2011
  8. Christakis, NA and Fowler, JH. Social contagion theory: examining dynamic social networks and human behavior. Stat Med. 2013; 32: 556–577
  9. Hipp, JA and Chalise, N. Spatial analysis and correlates of county-level diabetes prevalence, 2009–2010. Prev Chronic Dis. 2015; 12: E08
  10. Ferdinand, AO, Sen, B, Rahurkar, S, Engler, S, and Menachemi, N. The relationship between built environments and physical activity: a systematic review. Am J Public Health. 2012; 102: e7–13