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Self-assured commentators who saw Bangladesh as a basket case not many years ago could not have expected that the country would jump out of the basket and start sprinting ahead even as expres sions of sympathy and pity were pouring in. This infor-mative Lancet Series on Bangladesh16 helps to explain what happenedand why. It is important to understand how a country that was extremely poor a few decades ago, and is still very poor, can make such remarkable accomplishments particu larly in the eld of health, but also in social transformation in general.

The lessons are important for Bangladeshs own future, and for what The Lancet Bangladesh Team describe as the construction of a second generation of health systems.6

But the messages from Bangladeshs experience are also of great relevance for many other countries in the world that su er from debilitating poverty. It might not be good manners for Bangladesh to start lecturing the world on what to do, so soon after jumping out of the basket to which it had been relegated, but the countrys experience has important lessons for other developing countries across the globe.

These lucid and helpful papers discuss the main avenues of change on which Bangladesh has travelled. I will not summarise the ndings: this has been nicely done in the introductory paper by Mushtaque Chowdhury and colleagues.1 Instead I will concentrate on a small number of striking features of the strategy followed by Bangladesh in moving rapidly towards health transition.

One direction of change is the emphasis that the country has placed on reducing gender inequality in some crucially important respects. The impetus for the change was linked in many di erent ways with the politics of liberation that made the issue of freedom, including the liberation of women, a part of the progressive agenda of what people wanted and were ready to ght for. There are inescapably complex issues to be addressed in order to explain more fully how exactly that happened. It can be argued that there were historical elements in the culture of Bengal, and particularly in the emergence of radical movements in various forms in that province throughout the rst half of the 20th century, that leant them to include a serious concern for gender equity. But it was the nature of the struggle for independence of Bangladesh, particularly in focusing on the contrast with West Pakistan, that made it possible to make an e ective political translation towards empowering women.

The causation of this move towards gender equity cannot but remain somewhat speculative, but its con-sequences are clear enough. Schools focused particularly on expanding the education of girls: Bangladesh is one of the few countries in the world where the number of girls in school now exceeds the number of boys. Public ser vices, including school teaching, health care, and family plan ning, employ a much higher proportion of women work ers than is the case in most developing economies, includ ing in Bangladeshs neighbouring countries. Women have also entered the economic workforce in plentiful numbers, led by such industries as garment making that provided easy entry to female

10 Ministry of Health of the Peoples Republic of China. China report on the health hazards of smoking. Beijing: Peoples Medical Publishing House, 2012.

11 National Health and Family Planning Commission. Tobacco health education core information notice. http://www.smokefreehealthcare.org/kydt/kyxw/20130831/29156.shtml [in Chinese] (accessed Sept 2, 2013).

12 Federal Trade Commission. Federal Trade Commission cigarette report for 2009 and 2010. Sept 21, 2012. http://www.ftc.gov/os/2012/09/120921cigarettereport.pdf (accessed Aug 16, 2013).

13 English.news.cn. Chinese tobacco rms tax payments surge. Jan 17, 2013. http://news.xinhuanet.com/english/business/2013-01/17/c_132109059.htm (accessed Aug 16, 2013).

14 Hill C. La hausse des prix du tabac. Nov 19, 2012. http://societe-francaise-de-tabacologie.com/dl/CSFT2012-Hill_S1.pdf (accessed Sept 2, 2013).

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labourers, even though the neglect of safety at work has been a huge blot in the record of that industry, a serious de ciency that is only belatedly being addressed, and perhaps not yet strongly enough.

Women have also received special attention from Bangladeshs powerful non-governmental organisations (NGOs)from large initiatives like BRAC and Grameen Bank to smaller organisationsand the mobilisation of the active agency of women has been a distinctive feature of the vision that has moved Bangladesh forward. And there has been a general determination in post-independence Bangladesh to target the elimination of female disadvantage in di erent elds of action, including maternal and child survival.4

The removal of female disadvantage and the use of female agency have raised Bangladeshs record of achievement even on its own, but it is in fact the case that womens agency has also contributed greatly to the advancement of the lives and freedoms of allmen, women, and children. The unlocking of the power of womens active role in the society and in the economy has been an extremely productive move for Bangladesh and contrasts with what has happened in much of India.7 Bangladeshs powerful achievement in making much greater use of womens agency is a remarkable a rmation of the importance of what Mary Wollstonecraft called, in 1792, the vindication of the rights of woman.8 Indeed it turns out that the removal of the social shackles that restrain women has a crucial part to play in the progress of all peopleof both sexes and of all ages.

A second striking feature of the Bangladesh story is the general acceptance of a multiplicity of instruments in the public and private sectors for rapid social advancement. Just as state initiatives have been seriously undertaken, NGOs and private enterprises have been forcefully supplementing the e orts of the public sector. As Syed Masud Ahmed and colleagues2 argue, the use of pluralism has allowed Bangladesh to get o to a quick start bringing the country a little closer to a health transition.

This is not to deny that the mixture of instruments that characterise Bangladeshs path of development will demand critical examination over time, since substantial overall advancement can coexist with persistent inef- ciency and inequalities in the sharing of the bene ts of health transition. These evaluative issues remain open to scrutiny and critical examination, but what has to be immediatelyand rmlyrecognised is that Bangladesh

has been, in its own way, going ahead rapidly, rather than remaining paralysed by the slowness that is often entailed by the pursuit of purity in more ideologically oriented initiatives which favour either exclusive reliance on private enterprise or exclusive use of state-based programmes. The pragmatism that Bangladesh came to accept through a complex political and social process has yielded noticeable success, which has impressedand to a considerable extent surprisedthe world.

A third feature, closely related to the second, is the intelligent use of community-based approaches in the delivery of health services and medical care. As Shams El Arifeen and his coauthors3 outline, the mobilisation of community-based participation has many advantages, not only for the fostering of social cooperation, but also for extending the reach of the health initiatives and their impact. The innovations in health-service delivery from which Bangladeshis have bene ted have been possible partly because of these participatory features in the process of social change. The importance of innovations is also discussed in the context of equity in the paper by Alayne Adams and colleagues.4

A fourth feature, which demands particular attention in Bangladesh, is the countrys improved ability to face natural disasters, such as storms, cyclones, oods, and droughts. These natural calamities have acted as a persistent drag on the countrys progress. As the contributions by the Richard Cash and colleagues5 highlight, the deep vulnerability of the disaster-prone country to unruly forces of nature, which needed to be subdued, has indeed been, to a considerable extent, reduced. The elimination of these problems would, however, demand much more security-oriented progress in future years, especially if the threats for climate change become stronger.

I have pointed to a few of the special features in Bangladeshs progress towards a health transition, and many other features have been explored in this valu able Lancet Series. One very important aspect of this compendium of investigations is the continued focus on a call to action6 that nicely supplements the appreciation of what has been accomplished. Bangladesh has still a long way to go. This Lancet Series shows how Bangladesh has rmly placed itself on the way to that long journey (and has made an excellent beginning), but also points to further problems that have to be tackled as the journey pro ceeds. The key to

Man receiving treatment at the International Centre for Diarrhoeal Disease Research, Bangladesh, in 2009

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1968 www.thelancet.com Vol 382 December 14, 2013

On Dec 11, 2013, holding the presidency of the G8, the UK hosts a Dementia Summit in London to try to reach agreement on a new international approach on dementia research.1 Given the long list of problems facing the G8, why has Prime Minister David Cameron chosen to put dementia research centre stage? Although the devastating impact of dementia on patients and families has long been recognised, it is the projections

for future numbers of a ected individuals and the economic consequences that have surely focused the minds of international leaders.

Worldwide some 36 million people have dementia, with 66 million people estimated to be a ected by 2030.2 This so-called pandemic is due to ageing populations and the exponential relationship between age and the incidence of the major causes of dementia, notably

The G8 Dementia Research Summita starter for eight?

Bangladeshs laudable success has been the avoidance of the twin dangers of inertia and smug ness. The future will demand more from these virtues.

Amartya SenDepartment of Economics, Harvard University, Littauer Center, Cambridge, MA 02138, USAasen@fas.harvard.edu

I declare that I have no con icts of interest.

1 Chowdhury AMR, Bhuiya A, Chowdhury ME, Rasheed S, Hussain Z, Chen LC. The Bangladesh paradox: exceptional health achievement despite economic poverty. Lancet 2013; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(13)62148-0.

2 Ahmed SM, Evans TG, Standing H, Mahmud S. Harnessing pluralism for better health in Bangladesh. Lancet 2013; published online Nov 21. http:// dx.doi.org/10.1016/S0140-6736(13)62147-9.

3 El Arifeen S, Christou A, Reichenbach L, et al. Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh. Lancet 2013; published online Nov 21. http://dx.doi.org/ 10.1016/S0140-6736(13)62149-2.

4 Adams AM, Rabbani A, Ahmed S, et al. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. Lancet 2013; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(13)62060-7.

5 Cash RA, Halder SR, Husain M, et al. Reducing the health e ect of natural hazards in Bangladesh. Lancet 2013; published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(13)61948-0.

6 Adams AM, Ahmed T, El Arifeen S, Evans TG, Huda T, Reichenbach L, for The Lancet Bangladesh Team. Innovation for universal health coverage in Bangladesh: a call to action. Lancet 2013; published online Nov 21. http:// dx.doi.org/10.1016/S0140-6736(13)62150-9.

7 Dreze J, Sen A. An uncertain glory: India and its contradictions. London: Penguin, 2013.

8 Wollstonecraft M. A vindication of the rights of woman. London: Penguin, 2004.

Panel: Eight recommendations for the Dementia Summitcommitments and coordination

1 Each of the G8 countries should develop a national dementia plan and commit to publish annually the cost to their nation of dementia and what they are spending on dementia research.

2 Each of the G8 countries should commit to sustained increases in national dementia research budgets. It is only right that a collective commitment is made: each nation should agree to double their funding for dementia research within 5 years and bring it up to 1% of their national dementia costs within 10 years.

3 There should also be a commitment to coordinate research e orts and for collaboration to be underpinned by an international fund ring-fenced for international research programmes. If it is scienti cally sensible for groups to collaborate, then we need to remove disincentives to do so.

4 International cohorts and registries need to be established to study the natural history of di erent dementias and make it easier for patients to be recruited into trials.10

5 A task force should be established to consider what can be done to accelerate and incentivise the development, testing, and approval of new therapies, including reducing regulatory burden and delay.

6 Alongside pharmacological interventions to delay onset, we need international research on dementia prevention through the reduction of risk factors, many of which, such as cutting rates of smoking, have wider bene ts too. A focus is needed on joint working to establish the methodology, cohorts, and ethical and regulatory frameworks to undertake prevention trials.

7 How best to deliver care is an important area for research. Di erent societies have di erent approaches, and we need to learn from each other and research best practice.9 We need to be able to discuss di cult areas, including those around end-of-life care. We need an international push to involve a much higher proportion of carers and patients in research.

8 We must maximise the international bene t of data currently being collected and nd e ective ways to share, which include enabling access to all data from clinical trials.11 Not only should the G8 encourage pharmaceutical companies and academia to do this, but it should contribute to building the infrastructure for safe data curation, quality control, and managed release of patient-level data that will allow access while protecting con dentiality.

Published OnlineDecember 11, 2014

http://dx.doi.org/10.1016/S0140-6736(13)62426-5

Whats happening in Bangladesh?References