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

Lead Research Organisation: University of Cambridge
Department Name: Public Health and Primary Care

Abstract

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.

Technical Summary

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.

Planned Impact

IMPACT SUMMARIES

The ultimate desired impact of this initiative is a real-word sustainable gain in health (eg, material reduction in disability and/or prolongation of life), leading to improvements in human welfare and economic advancement in Bangladesh.

We acknowledge that such an impact is unrealistic within a 4 year grant period, especially since the funding call requests "feasibility, scoping, exploratory, proof of concept studies" (rather than fullscale implementation trials).

Hence, key "intermediate" impacts to be achieved in the grant period through routes described in the Pathways to Impact statement include:

1) Systematic review, systems modelling, and proof of concept studies of several practicable, scalable and effective interventions that can help protect against NCDs, and understanding of their inter-dependencies, setting the stage for definitive separately-funded studies of interventions

Research findings from this project will be relevant to many aspects of the social, physical, and economic environment
We will contribute to the evidence in these areas and directly influence practice and policies at local, regional, national and international levels

2) A novel partnership between key Bangladeshi and UK organisations that will promote enduring relationships based on shared values and a common research agenda

Policy makers will benefit directly from the results of modelling and through using the models to consider different policy scenarios and assess proposed changes. The models will improve the ability to predict likely effects of interventions before deciding how to invest resources in real interventions, a major benefit for Bangladesh's resource-constrained authorities
We recognise that impact is a 2-way process, with our research priorities shaped by policy and public health needs, encouraging us to pursue a partnership approach, co-producing tools and publications and working closely with policymakers and public health practitioners.

3) A cross-disciplinary network of researchers, policy-makers, and other key stakeholders across the UK and Bangladesh committed to a shared research vision

Civil society organisations, NGOs, and campaigners represent other potential audiences for our evidence outputs and may present research opportunities
Our findings should provide better services and lead to a stronger evidence base for this implementation work (eg, BRAC WASH programmes).

4) Training of a cadre of several dozen applied researchers in Bangladesh and the UK capable of sustaining excellent research and effective action in the face of complexity, to combat adverse health effects of environmental exposures

5) A transformative100,000-participant multi-purpose research platform that can be enriched and harvested on an ongoing basis to inform policy and health practice in Bangladesh

The impact of this cohort could be analogous to the "cohorts/panels" created by the ESRC and MRC in the UK during the past 50 years; several have led to major research and societal advances, such as understanding of the relevance of social determinants of health (Whitehall cohort), the hazards of smoking (British Doctors' Study), and the prevention of cot death (ALSPAC)
This research platform will give the Bangladesh research and policy communities similar advantages to those accruing in other low- and middle-income countries that have created such cohorts suited to national circumstances, including China (500,000-participant Kadoorie Biobank) and Mexico (150,000-participant Mexico City Prospective Study).

Publications

10 25 50
 
Description Cambridge alliance to protect Bangladesh from long0term environmental hazards
Amount £7,946,901 (GBP)
Funding ID MR/P02811X/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 10/2017 
End 12/2021
 
Title BELIEVE Urban 
Description Collection of data from the BangladEsh Longitudinal Investigation of Emerging Vascular Events in urban setting (BELIEVE-Urban) study: The study, in collaboration with National Heart Foundation in Bangladesh, aims to recruit up to 80,000 community-based individuals (age >5 years) from households in Bangladesh. The study population will be recruited through household survey (initially in urban areas of Capital Dhaka, and then from a semi-rural Sylhet region) to ensure maximum and generalizable participation, particularly from individuals with shared environmental and genetic background. The key objectives of the BELIEVE Urban prospective cohort study are to create a re-callable population and bio-resource involving a general South Asian population to: (1) enable genetic discovery using diverse phenotypes (particularly those related to nutrition such as anaemia, infection, or environment-related aspects such as air and toxic metal pollution), causal evaluation and functional genomics; (2) assess reliably the roles of established and unique locally-relevant risk factors on incident NCDs such as cardiovascular, cancer, diabetes and kidney diseases (ascertained by clinical records and standardised validation); (3) help study discrepant risk factor patterns unique to this population (eg, unusually high tobacco usage, lowest average body mass index, highest physical inactivity rates) over time, in various age groups as a life-course approach; and their heritability; and (4) create a well-characterised population base to set-up innovative and cost-effective behaviour modification and pharmaceutical interventions, suitable from a South-Asian context. 
Type Of Material Database/Collection of data 
Year Produced 2017 
Provided To Others? No  
Impact None yet, samples and data still being collected and analysed. 
URL http://www.capable-bangladesh.org/cohorts/believe-urban/
 
Description CAPABLE - BSMMU 
Organisation Bangabandhu Sheikh Mujib Medical University
Country Bangladesh 
Sector Academic/University 
PI Contribution Intellectual input and scientific direction/coordination to help set up a research cohort to better understand disease and environmental risks in Bangladesh. Coordinating centre for the CAPABLE programme under which this collaboration sits.
Collaborator Contribution Intellectual input and scientific direction/coordination to help set up a research cohort to better understand disease and environmental risks in Bangladesh. Provision of staff, resources, space.
Impact No outputs yet.
Start Year 2017
 
Description CAPABLE - IEDCR 
Organisation Institute of Epidemiology Disease Control And Research
PI Contribution Intellectual input to the research into environmental and lifestyle risk factors in Bangladesh with respect to non-communicable diseases, as well as the planning and coordination of capacity building and training in the programme. Coordinating centre responsible for the CAPABLE consortium under which this collaboration sits.
Collaborator Contribution Intellectual input to the research into environmental and lifestyle risk factors in Bangladesh with respect to non-communicable diseases, as well as the planning and coordination of capacity building and training in the programme. Provision of space and resources for capacity building elements of the programme.
Impact Not outputs yet.
Start Year 2017
 
Description CAPABLE-University College London 
Organisation University College London
Department Institute For Global Health
Country United Kingdom 
Sector Academic/University 
PI Contribution Intellectual input and scientific direction/coordination to help set up a work stream on social determinants and better understand disease and environmental risks in Bangladesh.
Collaborator Contribution Intellectual input and scientific direction/coordination to help set up a work stream on social determinants, policy and gender studies to better understand disease and environmental risks in Bangladesh. Supervision of fellows, capacity building.
Impact No outcomes yet
Start Year 2017
 
Description CAPABLE-University of Aberdeen 
Organisation University of Aberdeen
Country United Kingdom 
Sector Academic/University 
PI Contribution Intellectual input and scientific direction/coordination for studying arsenic and other environmental toxic metals. Coordinating centre for analytical analyses in biological and non-biological samples.
Collaborator Contribution Intellectual input and scientific direction/coordination to better understand disease and environmental risks in Bangladesh. Provision of staff, resources, space, capacity building, development of novel analytical methods to study the concentration of toxic metals in biological and non-biological samples.
Impact No outputs yet
Start Year 2017
 
Description University of Massachusetts - Larry King 
Organisation University of Massachusetts
Country United States 
Sector Academic/University 
PI Contribution Prof. King is a co-PI on the CAPABLE programme funded by UKRI.
Collaborator Contribution Take part in operational and scientific meetings, provide scientific inputs, write project proposals, contribute in scientific papers, and other activities as requested by the CAPABLE Executive Committee. Co-lead the work of analysing social determinants of risk factors in the CAPABLE programme.
Impact none yet
Start Year 2018
 
Description CAPABLE Bangladesh Launch 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Bangladesh launch of CAPABLE programme, talks given, press spoken to and site visited. Generated lots of debate and in country press articles.
Year(s) Of Engagement Activity 2018
 
Description CAPABLE General Assembly (John Danesh) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Annual general assembly of CAPABLE programme, gathering of all collaborators, staff members, supporters, extended network, donors and other stakeholders. Talks, debates, working groups
Year(s) Of Engagement Activity 2018
URL http://www.capable-bangladesh.org/capable-in-popular-media/meeting-september-2018-uk/
 
Description CAPABLE workshop in Bangladesh (Emanuele Di Angelantonio) 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Travel to Dhaka to plan implementation of CAPABLE study, with Scientific Planning Committee Meeting, site visits and meeting collaborators
Year(s) Of Engagement Activity 2018
 
Description Cambridge GCRF launch event 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Visit by politicians (Joe Johnson) and RCUK representatives to promote the GCRF projects funded at the University of Cambridge, including presentations to these stakeholders.
Year(s) Of Engagement Activity 2017
 
Description Cambridge Science Festival 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Helping out at the "Hands On" stall by the Division of Cardiovascular Medicine, giving a talk with 'Out-thinkers' and running a live action game event aimed at teaching 30 school children about the complexity of dealing with emerging epidemics.
Year(s) Of Engagement Activity 2018
URL https://www.sciencefestival.cam.ac.uk/about/past-festivals/2018-festival
 
Description Teaching at Short Course in Dhaka, Bangladesh (Emanuele Di Angelantonio) 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Teaching on Short Course in Dhaka, Bangladesh organised by UK Universities to extend knowledge and educate as part of CAPABLE study
Year(s) Of Engagement Activity 2018