I have made an interesting contact here in Bangladesh. Dr. Kazi Bennoor is an MBBS (Bachelor of medicine and surgery) physician and assistant professor of respiratory medicine at the “National Institute of Diseases of the Chest and Hospital“, in Dhaka. I contacted him initially back in June while performing a Google search on the “American Thoracic Society (ATS) questionnaire in Bangla”. Since I had been planning on using it as a large component of my questionnaire for the shipbreakers, I wanted to see if somebody had already used it in another Bangladesh based study. He told me he had used a version of this questionnaire in a published study on asthma prevalence in Bangladesh, and another study in the works on prevalence of Chronic Obstructive Pulmonary Disease (COPD). I hadn’t considered contacting him again until recently; Zakia and I have been pilot testing the questionnaire on local rickshaw pullers and construction workers, and a few questions/concerns have arisen. I remembered Dr. Bennoor, contacted him, and met with him the same day. The hospital started off as a tuberculosis (TB) sanitarium in 1955, and therefore is known to locals as the “TB hospital”. Today it is the only tertiary care hospital in Bangladesh for chest diseases. It offers an MD degree in chest diseases and an MS degree in thoracic surgery; it is affiliated with University of Dhaka.

Dr. Bennoor looked briefly at the Bangla version of my questionnaire and said that yes, it was almost exactly translated they way theirs had been. They used their ATS questionnaire for two studies so far. One on asthma that was published in the International Journal of Epidemiology in 2002 entitled, “Self reported asthma symptoms in children and adults of Bangladesh: Findings of the national asthma prevalence study”. In this study 5642 people were interviewed, and the questionnaire had been pilot tested in 10 districts (of 64) in Bangladesh as all regions have slightly different dialects, including two districts next to Bogra. The second study it was used for, was a COPD study that has not yet been published, but over 3000 people have been interviewed with it. He said they made slight adjustments to the ATS questionnaire; for example, one question asks if the subject can unbutton and button his shirt without feeling breathless, but in Bangladesh most people don’t have button up shirts, so instead they asked, “Can you perform Ozu, or the washing up before prayer time, without feeling breathless?” He has offered to look over the Bangla and English questionnaire over the Eid holidays (next week) to let me know if he has any suggestions for areas I could alter.

He was very interested in “B Readers” as he was not familiar with them and is keen to learn more. A B Reader is a specialized radiologist who demonstrates proficiency in the classification of chest radiographs for the pneumoconioses using the International Labour Office (ILO) Classification System. With enough clinical and work history information, along with a good quality chest x-ray (CXR), a B Reader can examine the CXR and distinguish between silicosis and asbestosis. A B Reader from the University of Washington will be examining my shipbreaker CXRs. Dr. Bennoor explained the diagnostic facilities at his hospital are not good enough to diagnose interstitial lung diseases (ILD), much less the source of it (in my case, asbestosis and asbestos, respectively). The idea of training B Readers in Bangladesh could be an exciting , feasible future project here in Bangladesh, and something the ILO could even become involved in.

Diagnosis and treatment protocols are available for:

• TB – Uses WHO guidelines (and in addition, a campaign by the National TB Program that urges people who have a chronic cough for > 2 weeks to go to a hospital)
• Pneumonia – Uses acute respiratory tract infections (ARI) guidelines
• Asthma, bronchiolitis, and COPD – Uses guidelines created by the Asthma Association of Bangladesh. I currently have a copy of their third edition from 2005
• ILD – No guidelines and in Bangladesh has not been explored. Dr. Bennoor is very interested about the magnitude of the problem here, and therefore seemed all the more interested in our study.

These available protocols, along with a better idea of what is not available, will help immensely with the “case management strategy” we are creating.

Dr. Bennoor asked why we were not performing spirometry (breath measurements) with the 100 shipbreakers in Bogra as it would only add 10 minutes onto each interview. Initially my committee had brought it up, but there was an issue of not having the equipment, not being sure of the cost, and not wanting to make the project any larger. Well, Dr. Bennoor has offered to lend us his portable one for my time in Bogra. He demonstrated to me how to use it and explained a relatively simple procedure of reading the FEV1 (forced expiratory volume in 1 second) and FVC (forced vital capacity) off the screen and taking the ratio. After discussing this with my committee however, it seems as if the procedure should be quite a bit more complicated than this and so I am not sure at this moment if we will go through with it.

I believe Dr. Bennoor will be a key contact here in Bangladesh and a meeting with him should be arranged when a couple of my committee members visit in November/December.

A very important lesson I have learned in “miscommunication” from working here will be illustrated to you from a recent experience:

I was attempting to arrange a time when I could present my introduction to bulk asbestos identification with students, faculty, and laboratory technicians. I was told that with exams this week, the following week would be better. I marked down a time and date in my agenda, and noticed that I was the only one writing anything down, which made me a little nervous, but I did not think it would be appropriate to suggest the information to be written down in such a forward manner! The next morning, I received a phone call asking if I was going to be presenting the asbestos information!! I replied in a bit of a panic that no, it was scheduled for the following week and was not ready yet. I rushed over to the office, trying not to get frustrated, but having frustration written all over my face I am sure. I sat down while the scheduling was discussed amongst three Bangladeshi professors, in Bangla. I was trying to understand what they were saying, but was unable to follow. It was finally explained to me that, next week, all the students would be gone on a field trip somewhere far away, and although we had decided on next week, the responsibility seemed to lie in my court. We compromised for the following day.

New strategy: email a summary of items discussed at meetings as a record for yourself, but also for the other party to avoid as many ambiguities and confusion as possible. They do not have to necessarily be formal minutes, but just a quick recap of dates, deadlines and agreements in the form of an email could prove to be very useful.
Despite all this, the presentation was a success. Approximately 20 students, 5 professors and 3 lab technicians from the department of Occupational and Environmental health were present. The presentation consisted of:

• An introduction to asbestos including the properties of asbestos, the regulated fibres, common uses, health effects and a brief history of mining
• Mineralogy concepts including refractive indices
• Introduction to the components of a polarizing light microscope
• Step by step procedure of bulk asbestos identification

The presentation generated some lively discussion, mostly around what clues first trigger people to suspect some material may contain asbestos, then go on to collect a sample to be analyzed. Someone also asked how this relates to my project, which is interesting because of course, it doesn’t really relate to it anymore. I explained how my original idea for an exposure assessment study evolved into the health outcome study it is now, and so I would no longer be using identification in my study. Dr. Akhtar then mentioned that next year, he has plans for at least a couple of his students to take on projects that would utilize the polarizing microscope I brought, for asbestos identification.

Dr. Akhtar raised an interesting point I had never heard actually; I have always understood that while all asbestos is harmful, amphibole asbestos (crocidolite and amosite) is believed to be worse than serpentine (chrysotile), in that serpentine asbestos (the wavy, soft looking fibres) break down a little faster in the lungs than amphibole asbestos (the sharp needle-like fibres). However, Dr. Akhtar states serpentines to be more harmful than amphiboles because the curly nature of serpentine keeps fibres trapped in the lungs, while amphiboles are more easily brought up with natural clearing of the lungs.

The presentation was to be followed by a demonstration with the microscope I brought with me from Canada: one with the professors and one with the laboratory technicians. Prior to this I spent a few days setting up the microscope and making sure all the components were working as they should. The microscope I brought is the Meiji ML6120 polarizing light microscope for bulk asbestos identification. It has built in Koehler illumination which my friends at the McCrone Research Institute would not be pleased about, but otherwise, all other components are manually adjustable, and it is a reasonably priced piece of equipment that does the job. I decided the demonstrations would have to be with asbestos slides I prepared back in Canada using Cargille Meltmount™, because even though I brought Cargille™ dispersion oils with me, a proper fume hood will have to be constructed with a high efficiency particulate air (HEPA) filter before asbestos mounts can be prepared here. Slide mount demonstrations would be with fiberglass or some other man made fibre.

Training the professors went quite well. Although it was getting later in the day and everyone was losing energy pretty quickly due to this being Ramadan month (the month of fasting), everyone seemed very enthusiastic about getting their hands on the microscope and trying to identify the different types of asbestos. I had been warned before that as a younger woman, male professors might not cooperate and listen as readily as if I had been male, but I had all the professors’ undivided attention for about 3 hours and went through the steps of bulk asbestos identification with ease. They have a good handle of the concepts, and it seems to me they were enjoying themselves.

Training the laboratory technicians was not quite as successful. Main problem was, they don’t speak English. I went to Dr. Akhtar and asked how I should train them properly and he replied half jokingly, “you must train with little bit broken Bangla”. I tried to at least demonstrate the steps without much verbal communication, and they were all smiling and nodding, eager and willing to learn, but then when I asked them to do it on their own, they had no idea what to do. They were moving lenses around they weren’t supposed to be moving and well, it was a bit disastrous! Afterwards Dr. Akhtar asked how it went, and I gave him a look as if to say, it most certainly did not go well. He laughed and said, now that I have gone through it with them once, he will be there to explain things they don’t understand. I am not fully satisfied with that approach yet, but I will try to strengthen that a bit by making some more flow-charts with steps clearly laid out, and some colour photographs.

As for the fume hood situation, I have sent home photos of the fume hoods to get some advice from a ventilation expert, on whether or not we can place a HEPA filter somewhere in this existing structure, or if we will need to construct a little fume hood here and have one of my committee members coming out in November, to bring some HEPA supplies with them.

Dr. Nurun Nahar is the district (of which there are 64 in Bangladesh) top health authority of Bogra, also known as the district civil surgeon. During the feasibility trip in April, we met with her, explained my study, and she has been a strong supporter of this project ever since. I traveled up to Bogra from Dhaka for a day to meet with her and discuss some burning questions my committee and I have been going over for weeks.Covered with Dr. Nahar:
• Flooding situation
• My proposed schedule for enrollment in villages and use of hospital
o Enrollment of respondents; travel arrangements
o Hospital arrangements: booking consultation room; x-ray facilities
• ATS (American Thoracic Society) questionnaire
• Upcoming elections

At hospital:
• Tour of Mohammed Ali 250 bed Government Hospital in Bogra city
• Case management strategy

During the recent floods, about half the area of villages where I plan to enroll respondents were affected by flooding. The water has receded and although there are now problems with water borne diseases, these will all have settled down by the time we arrive to begin the study in the second week of October.

Dr. Nahar suggested it would make more sense to go the villages one day a week to enroll subjects and then use the hospital 4 days a week for interviews/x-rays. We will have an assistant health inspector with us for that one day a week, to help us find shipbreakers within the village and translate local dialogue even my research assistant may not understand. He will also help us explain to those who have agreed to participate, directions to the Mohammed Ali Hospital in a manner they will understand. The hospital, located in Bogra city, is completely available to me for interviews and x-rays, but is open only until 2:30 pm, so with the length of time I think the interviews will take, we will probably get through four interviews and x-rays per day maximum. A meeting will be arranged for October 12, the day I move to Bogra, with the Civil Surgeon, the assistant health inspector, a health officer from the villages, Zakia, and myself to discuss these arrangements in more detail.

There are about 20 villages, so with 10 weeks, or 9 total days for going to villages, I could go to at least 2 villages, sometimes 3, and enroll about 12-16 people on each enrollment day. These 12-16 people would be given instructions to come to hospital on specific appointment time during the following week. My first priority will be enrolling respondents from different job categories (cutters, loaders, fitters, cable pullers, etc) in order to stratify by job-title. Since the vast majority of the shipbreakers I find will be loaders, after finding those from other job categories, I will stratify the remaining loaders by length of time since first year on the job.

Back in Dhaka, I have just begun pilot testing my questionnaire with my research assistant, Zakia. Last week we interviewed a rickshaw wallah, thinking they would be of a similar socioeconomic status as shipbreakers, and when I return to Dhaka tomorrow, we will be interviewing a construction worker, who will have exposure to unknown dusts and may experience lung problems. The questionnaire itself I have designed using the framework of the well validated questionnaire by the American Thoracic Society (ATS). However, I am not sure if the questions can completely relate to this demographic. This is a concern I brought up with Dr. Nahar and she smiled knowingly when I told her most people do not seem to understand most of the terminology; I asked if she uses a standard questionnaire with her patients in her tuberculosis screening program and she said yes but apparently I will not be able to see a copy of this until I return to begin my field work. Dr. Nahar’s English is quite good, but I was not able to fully understand what the reason for this was. I believe there is an organization in Bangladesh that has used this questionnaire for a study on prevalence of COPD, so I will be contacting them to see how they were able to use the ATS questionnaire.

Dr. Nahar believes the upcoming elections will not affect the study at all. These are elections that were meant to happen in 2006, but due to party conflicts and corruption charges, it has been put off until now. Elections are slated for Dec. 18th, and due to all the problems elections caused while I was here in 2006, I clarified this with her once more. She assured me they will not be a problem at all; last time Bangladesh was under the power of the BNP government, one of the two main political parties, entering the elections. This time, the elections are being held under a neutral government and there will not be the same sorts of problems. She also said there will be no problems coming to Bogra from Dhaka during these next few months. I have in fact not yet come across one person who seems to think the elections will pose any problems.

During my visit to the Mohammed Ali Hospital later that day, I met first with the two resident medical officers who were already well aware of my whole project and had a very good understanding of exactly what I needed. They were extremely helpful and cooperative. They gave me a tour of the hospital, including the radiology department, where I was introduced to radiologists and technicians. They assured me 4-5 x-rays a day will be no problem at all, and even if they are busy, they will always make time to accommodate me, and they are indeed film x-rays, not digital. They offered to interpret the films for me and provide me with a report.

I then asked them about case management strategy. They said they have protocols for diseases/disorders such as tuberculosis, pneumonia, chest pain, cough, fever, weight loss, and anorexia. I told them that what I was trying to understand was the state of local general practitioner knowledge of other lung pathologies and what is needed on our end; what kind of document would be useful and appropriate to create for them, for the different pathologies we might come across, and asked them to run me though an example protocol for tuberculosis:

Patient comes in to hospital with chronic cough (> 15 days) or chronic fever, maybe weight loss, anorexia, loss of appetite, and tuberculosis is suspected. Next they investigate by taking blood, sputum AFB smears and maybe even a chest x-ray. Mainly rely on sputum. If positive for TB, they start anti-TB therapy given by DOTS (directly-observed therapy short-course). Follow up after 2 months by taking sputum smear again.

They reiterated there is no knowledge of what to do for patients who should show up at hospital with asbestosis or really, any other lung disease other than tuberculosis, pneumonia or chest pain. I was hoping my visit here would shed some light on how best to go about designing a case management strategy for these other diseases. Now, I believe the best action would be to outline a brief skeleton document with pathology description, prognosis, treatment, follow-up recommendations, and therapy if any, then determine what resources are available here that would allow this document to be utilized effectively.

My living conditions here consist of your basic dorm with ceiling fan, bed, desk, and even a sit down toilet. Never mind that it has permanent streaky stains on it! There is no regular schedule for the water, which comes about three times a day, so I leave all the taps on and as soon as I hear water trickling in the bathroom, it’s a mad rush to shower, flush the toilet, wash clothes and do the dishes. The situation with power outages a couple times a day, I was already used to from the last time I was here, and with a laptop, I can just go on typing away in the dark while everything shuts down around me. Pretty soon, I won’t even flinch, and I might not even notice until I realize that without the fan, I am typing away in a pool of sweat. A little word of advice for anyone doing work where internet access is not always readily available, get yourself a wireless modem. This is brand new technology for me, so I am not entirely sure how it works, but in my case at least, I have an EDGE (Enhanced Data rates for Global Evolution) modem, that sticks into my laptop, takes up no room at all, and requires the SIM card (that little card in your phone) of a local phone provider. It is bizarre, even at times when I have no power (like right now) and no water, I can still spy on my Facebook friends!

But looking on the bright side, I have my own private room and bathroom which is more than most people here have. I have also secured myself a gas stove, cylinder of gas, and the typical Bangladeshi aluminum conical cooking pot, so I can cook for myself. Without a fridge, my food has to be prepared fresh, and well of course there is nothing more refreshing than a warm beer to wash it all down! Other than the constant heat and strange smells (sometimes sewage, sometimes fish) drifting through once in a while, I am getting used to it and I might even say it is starting to feel like home.

We attempted our first thesis committee meeting last week.

My committee consists of Dr. Ahktar (NIPSOM, Bangaldesh), Dr. Hugh Davies (UBC), Dr. Paul Demers (UBC), and Dr. Tim Takaro (SFU). A lot of emails fly back and forth before a meeting like this can be arranged, not only due to the time difference, but also differences in available technology. We decided on using Webex, an online meeting centre which allows any number of people to get together for conferences, using an internet connection and a phone number to call into. The latter proved to be the more difficult challenge. In preparation for the meeting, I did a practice run using Skype but the static was bad and I was not always able to connect. In the next attempt, we tried the WebEx Integrated VoIP option and got it to work. This option meant I did not have to call in, but just to plug a microphone into my computer while I logged onto the meeting online. Alas, although this worked during the practice run, during the real meeting, there was a huge delay in speech and apparently I sounded like I had been breathing helium for breakfast. Needless to say, we spent the first half hour toying with different options and I ended up calling in on my mobile. This was marvelous for a little while, until my credit ran out and my Canadian committee found themselves talking to Alvin of “the Chipmunks” again.

Despite the technical difficulties, we managed to discuss the main items:

• Status of Bangladeshi ethics application, and Bangladeshi translations of the consent form and questionnaire
• A two-day trip to Bogra to meet with the Civil Surgeon and see study location before field work begins in October
• Obtaining an English translation of a map of the villages in Bogra in order to plan the enrollment strategy
• Status of fume hoods available at NIPSOM and whether or not they are appropriate for working with asbestos
• Creating a case management strategy, for local physicians who may be confronted by study respondents who have asbestosis or other pnuemoconioses

Interestingly, the ethics application, reviewed by the Bangladesh Medical Research Council, cost about $15, but it has been approved. The questionnaire will be pilot tested before final changes are made and sent back to Canada. It is our intention to “back translate” the questionnaire and consent forms in Canada, from Bangla to English, to ensure the original meaning has not been lost. Zakia, my research assistant, and I will pilot test the questionnaire on two cooks at the school, as Dr. Akhtar felt they would have a similar educational level and socioeconomic status as the shipbreakers we will encounter up north.

A trip to Bogra will be arranged for next week to meet with the Civil Surgeon, Dr. Nahar. I will visit the study locations including the Mohammed Ali District hospital in Bogra where the physical examinations and x-rays are to take place. During this visit I would like to gain a better understanding about the finer details in arranging appointments, available transportation for myself as well as the study respondents, available equipment and consultation rooms, etc.

Before coming to Bangladesh, an assistant health inspector in Bogra surveyed the study location to gain a general understanding of where shipbreakers were mainly located, what sorts of tasks they performed on the yards and how long they had worked for. Maps are not something that is commonly used in Bangladesh. Even in the city, local people do not use maps and have a hard time recognizing locations on maps if you open one up. Therefore, detailed maps of my study location do not exist, but the assistant health inspector was able to write in village names on a more basic map of the area. We initially wanted to use this at the committee meeting in order to discuss an enrolment strategy, but all names had been written in Bengali script and we will have to wait for it to be translated to English before we can discuss it again.

I was a little worried about the state of the fume hoods here, the fact that HEPA filters are not available in Bangladesh, and the attitude towards “small amounts of asbestos” not being a huge health risk. I have sent pictures of the fume hoods here to Canada, and we agreed on consulting with a ventilation expert in Vancouver to decide what materials can be brought over in November when some of the committee members visit. Apparently a large tax has to be paid on this end when receiving any sort of laboratory equipment by mail, so it is preferred to have equipment brought over in person.

Finally, we would like to begin designing a “case management strategy” for the local physicians. Once we have reviewed the x-rays, we may have a diagnosis of asbestosis, or another lung disease. The study does not have a medical follow-up component so it is important to provide some guidelines we can give to local physicians. The average Bangladeshi physician is very familiar with diseases treated every day such as tuberculosis, pneumonia and bronchitis. Most are unfamiliar with asbestosis and other fibrotic diseases. How best to go about designing this is still being thought through, but hopefully my visit with Dr. Nahar in Bogra will shed some light as well.