Table of Contents
Reframing NCDs? An analysis of current debate
There have been many debates in recent years as to whether the communicable disease versus non-communicable disease (NCD) division is a meaningful one in disease classification. Several critiques have been raised about the framing of NCDs, regarding not only the prominent role that infections play in the aetiology of NCDs, but also the communicability of many social determinants of NCDs and the individualistic, ‘lifestyle’ framing of NCDs that tends to focus on health behaviours to the neglect of socio-political, environmental, and structural determinants of health. In this paper, we give a historical overview of the usage of the NCD terminology and analyse some of the recent debates regarding the naming and framing of NCDs. We argue that a lack of reflection on the assumptions underlying the naming and framing of NCDs may lead to the collection of insufficient epidemiological data, the development of inappropriate interventions and the provision of inadequate care. Work in social epidemiology, health promotion, medical anthropology, demography, and other fields may provide insights into the ways in which efforts targeting NCDs may be reframed to improve impact and efficacy. In addition, concepts such as multimorbidity and syndemics, frameworks such as ecosocial theory and approaches based in the social sciences may provide a way forward in the conceptualization of disease.
KEYWORDS: Non-communicable diseases, social determinants of health, epidemiology, health transitions
Growing a social brain
It has long been assumed that social animals, such as humans, are born with a brain system that has evolved to support social affiliation. However, the evidence does not necessarily support this assumption. Alternatively, social animals can be defined as those who cannot survive alone and rely on members from their group to regulate their ongoing physiology (or allostasis). The rather simple evolutionary constraint of social dependency for survival can be sufficient to make the social environment vitally salient, and to provide the ultimate driving force for socially crafted brain development and learning. In this Perspective, we propose a framework for sociality and specify a set of hypotheses on the mechanisms of social development and underlying neural systems. The theoretical shift proposed here implies that profound human characteristics, including but not limited to sociality, are acquired at an early age, while social interactions provide key wiring instructions that determine brain development.
Agency, embodiment and enactment in psychosomatic theory and practice
Kirmayer, L. J., & Gomez-Carrillo, A. (2019). Agency, embodiment and enactment in psychosomatic theory and practice. Med Humanit, 45(2), 169-182. doi:10.1136/medhum-2018-011618
In this paper, we examine some of the conceptual, pragmatic and moral dilemmas intrinsic to psychosomatic explanation in medicine, psychiatry and psychology. Psychosomatic explanation invokes a social grey zone in which ambiguities and conflicts about agency, causality and moral responsibility abound. This conflict reflects the deep-seated dualism in Western ontology and concepts of personhood that plays out in psychosomatic research, theory and practice. Illnesses that are seen as psychologically mediated tend also to be viewed as less real or legitimate. New forms of this dualism are evident in philosophical attacks on Engel’s biopsychosocial approach, which was a mainstay of earlier psychosomatic theory, and in the recent Research Domain Criteria research programme of the US National institute of Mental Health which opts for exclusively biological modes of explanation of illness. We use the example of resignation syndrome among refugee children in Sweden to show how efforts to account for such medically unexplained symptoms raise problems of the ascription of agency. We argue for an integrative multilevel approach that builds on recent work in embodied and enactive cognitive science. On this view, agency can have many fine gradations that emerge through looping effects that link neurophenomenology, narrative practices and cultural affordances in particular social contexts. This multilevel ecosocial view points the way towards a renewed biopsychosocial approach in training and clinical practice that can advance person-centred medicine and psychiatry.