As pass the half-way point of my time in Bogra, Zakia and I have interviewed 55 former and present shipbreakers, and enrolled nearly 100. Despite the many challenges we have faced so far, I look at these numbers and feel a great sense of accomplishment. Of course, I also understand these accomplishments would not have been possible without my research assistant Zakia, and the Sariakandi assistant health inspector, Hannan. I thought in this entry I would recap how subject enrollment and interviews take place, and highlight some of the main challenges I have come across in the last few weeks.Enrollment takes place every Sunday (the Bangladeshi work week is Sunday to Thursday) and interviews, x-rays and physical exams take place over Monday through Thursday of the following week, thereby leaving a week in between. We started off enrolling 12 people a week and interviewing 3 each day, but once we established a routine, we were able to increase the enrollment to 16 people a week, or 4 each day.

As I mentioned in a previous entry, rumours about me performing vasectomies were flying around a particular village, and in the end, 8 out of 12 people from this village did not come for their hospital appointment. I expressed my concern to Hannan about whether or not they truly understood the study at all and what this says about the consent process, but he explained that it was not the men who did not understand the study. According to him, the men had understood what will happen to them at the hospital and why they are being asked to participate. However, in the morning when they were preparing to leave, their frightened wives were convinced their husbands were being led into some kind of trap where they would be sterilized at the hospital, and barred them in their homes until it was too late for them to make the appointment. At first this rumour seemed contained within one village, but a couple of weeks later, there was another whole village of participants nearby that withdrew at the last minute. Other than the people from these two villages, everybody has been arriving at the appointments on time, and I must say, they all seem very eager to participate.

Unfortunately, the pendulum has also swung too far the other way; a couple of times during recruitment, villagers would almost start fighting and the whole village would erupt in shouting and chaos. In my frustration, I would be begging Zakia to translate, and basically, some people wanted to participate, who did not meet my baseline criteria of having worked on a shipbreaking yard at least 10 years ago, for at least 1 year. The villages are open places and no matter how much you try to ensure privacy, you will never be able to obtain consent from someone without at least a few others listening in, so sometimes helpful neighbours will chime in and let us know that “so and so” only worked for 3 months or only worked 5 years ago, and then all hell breaks loose.

The first batch of 12 x-rays were couriered off to be analyzed as soon as possible in case there were any problems with them. For the most part, they turned out to be of acceptable quality, but a few of the main issues were:

1) The scapulae overlay the lung fields in some of the films; subjects needed to be instructed to roll their shoulders more forward

2) Some films were underpenetrated; the outline of the spine should at least be visible

3) With films being slightly smaller than average, subjects must be perfectly centred

4) The films are generally badly scraped, not to make them illegible, but they should be handled more carefully

I brought these issues up with the radiologist at the hospital, and although he seemed slightly defensive, he assured me these problems would be addressed. The second batch of x-rays has been sent out and I am waiting with fingers crossed that they have improved.

The interviews with the shipbreakers have been fascinating. Although I would love to post some tid-bits, in the interest of the study, I suppose I should not mention any “results-type” information yet. A slight problem I have encountered is when I am interviewing participants from the same village over two or three days, I found that sometimes they have spoken to one another at the village, and the first group has conveyed to later groups, exactly what I ask, and even describes the photographs I show towards the end of the interview.

The interview is split up into four parts. First are the standardized ATS (American Thoracic Society) questions. The next two deal with work and clinical history. The last part has to do with hazard perception/awareness and an attempt to see what/how much they know about asbestos and insulation. For this last part, I show photos of personal protective equipment (gloves, goggles, respirators, etc.) in order to determine which items they recognize, understand, or even use. I then show photos of insulation in different forms that are likely to contain asbestos (sprayed-on forms, pipe lagging, loose, ceiling tiles, etc.) to determine local names for asbestos or insulation and attempt to determine the fate of these substances. Well, was I ever surprised when a man, who had obviously been briefed the night before by a villager I had previously interviewed, explained in great detail about local names for insulation and the fate of the insulation, when all I had shown him by that point was a photo of a hard-hat. We addressed this issue by letting each subject know that everybody will see a new photo, never before seen by anyone else. Also, we remind them that it is perfectly fine if they do not know or recognize something, but just to be as honest as possible.

Hugh Davies, my thesis supervisor, and the principle investigator of this study, will be visiting Bangladesh next week. He will have the opportunity to observe a day of interviews at the hospital in Bogra and I am really looking forward to having him there and gaining some direct feedback; that is of course, as long as he does not tell me I should have been doing everything differently all along!!