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.