Cambridge Alliance to Protect Bangladesh from Long-term Environmental Hazards (CAPABLE)

近几十年来，孟加拉国一直处于快速转型之中：疾病负担已从以传染病、营养不良和分娩条件为主的情况明显转变为以心脏病发作、中风、糖尿病、肺部疾病和癌症等日益突出的慢性病(“非传染性疾病”)为特征的情况。据估计，如今孟加拉国至少有60%的成人死亡是由此类慢性病引起的。孟加拉国的慢性病不仅造成严重的残疾，每年导致数百万人死亡，还带来了重大的社会问题，限制了经济进步，减少了人类福利，并将稀缺的资源倾斜到昂贵的治疗上，而不是社会进步。这种情况是不可持续的，特别是在孟加拉国人口老龄化并继续增长的情况下。孟加拉国慢性病的原因包括独特的社会、环境和行为因素。例如，孟加拉国的环境和生活方式风险状况是世界上最糟糕的之一，其特点是：严重的水和空气污染：根据世界卫生组织(WHO)的数据，孟加拉国被砷污染的水是“历史上最大的人类大规模中毒事件”，影响到约1亿人。2016年世界卫生组织发布的一份关于环境空气污染的报告将孟加拉国列为全球污染第四严重的国家。营养失调：正常生长和发育所需的元素(如铁)缺乏的情况普遍存在。持续营养不良和新出现的肥胖的不断演变和复杂的背景也增加了疾病风险：“西方”生活方式(如不健康的饮食、缺乏运动)正在增加，并可能放大传统风险行为的不利影响，增加疾病风险。这些社会、环境和行为风险因素往往聚集在家庭中，分享前因和原因，放大彼此的影响，并以复杂(和不明显)的方式相互依赖。重要的是，它们还可以在不同的背景下发挥重要的不同影响，例如在农村、城市和贫民窟环境中。因此，可以结合起来而不是单独处理这些慢性病风险因素的方法可能会更有效，以及可以考虑到这些因素发生的背景的方法。然而，孟加拉国的研究基础设施没有被配置为评估该国的多重风险和多重环境，这可能会阻止出现可能表明“联合”解决方案的证据。我们的建议旨在应对这一重大挑战。我们将动员一个由来自孟加拉国和英国的7个组织的约25名主要调查人员组成的多学科团队，这些组织在合作方面有着良好的记录。我们将采取广泛的方法，重点关注以前没有在综合框架中考虑的慢性疾病的相互交织的风险因素。该计划为解决这一问题提供了一种全新的方法，因为它结合了四个创新和相互关联的组成部分：1)在城市、农村和贫民窟地区创建一个100,000名参与者的研究(“队列”)，以便能够研究慢性病的社会、环境和行为风险因素。2)开展跨学科研究项目，利用新的队列有助于了解风险因素的相互作用，以及如何利用社会学家、工程师、行为科学家、化学家、生物统计学家的互补优势，3)实施加强研究能力的综合方案，以三个相互关联的活动为目标：个人、组织和机构。4)动员和深化孟加拉国和英国英才中心之间的伙伴关系。

In recent decades, Bangladesh has been in the midst of a rapid transition: disease burden has shifted markedly from a profile dominated by infectious diseases, under-nutrition and conditions of childbirth to one increasingly characterised by chronic disease ("non-communicable diseases") such as heart attacks, strokes, diabetes, lung diseases, and cancer. Estimates suggest that at least 60% of adult deaths in Bangladesh today are due to such chronic diseases. As well as producing profound disabilities and cutting short millions of lives each year, the rise of chronic disease in Bangladesh has created major societal problems, limiting economic advancement, reducing human welfare, and skewing scarce resources toward costly treatments and away from social progress. This situation is unsustainable, especially as Bangladesh's population ages and continues to grow.The causes of chronic disease in Bangladesh include distinctive social, environmental, and behavioural factors. For example, Bangladesh has one of the world's worst environmental and lifestyle risk profiles, characterised by:Severe water and air pollution: According to the World Health Organisation (WHO), arsenic-contaminated water in Bangladesh, which affects ~100M people, is "the largest mass poisoning of a human population in history". A 2016 WHO report on ambient air pollution judged Bangladesh to be the fourth worst polluted country worldwide.Nutritional disorders: Deficiencies of elements (such as iron) required for normal growth and development are widespread. An evolving and complex background of persisting undernutrition and emerging obesity also increase disease risks.Risk behaviours: "Western" lifestyles (eg, unhealthy diets, physical inactivity) are increasing, and may amplify adverse effects of traditional risk behaviours, augmenting disease risk. These social, environmental, and behavioural risk factors tend to cluster in households, share antecedents and causes, amplify each other's effects, and depend on one another in complex (and non-obvious) ways. Importantly, they can also exert importantly different effects in differing contexts such as across rural, urban, and slum settings. Hence, approaches that could tackle such chronic disease risk factors in combination rather than in isolation are likely to be more powerful, as well as approaches that can take account of the context in which they occur. Yet, Bangladesh's research infrastructure is not configured to evaluate the country's multiple risks and multiple settings, perhaps preventing the emergence of evidence that could suggest "joined up" solutions. Our proposal aims to address this grand challenge. We will mobilise a multidisciplinary team of about 25 leading investigators from seven organisations in Bangladesh and the UK that have a substantial track-record of working together. We will adopt a wide-angle approach, focusing on intertwined risk factors for chronic disease that have not previously been considered in an integrated framework. The plan offers a fundamentally new approach to address this problem because it combines four innovative and inter-linked components:1) Creation of a 100,000-participant study ("cohort") in urban, rural, and slum areas to enable study of the social, environmental, and behavioural risk factors for chronic diseases.2) Conduct of cross-disciplinary research projects that will use the new cohort help understand the interplay of risk factors, and how to combat them, drawing on the complementary strengths of sociologists, engineers, behavioural scientists, chemists, biostatisticians, public health scientists and others.3) Delivery of an integrated programme of research capacity strengthening that targets three inter-linked levels of activity: individual, organisational, and institutional.4) Mobilisation and deepening of partnerships between Bangladesh and UK centres of excellence.