As expected the weeks are flying by. I should mention that my internship is now officially a WHO internship, and while I continue to work with ICDDR,B on the module of occupational injury questions for integration into their Health and Demographic Surveillance System, I have also been meeting and making contacts with other organizations relevant to occupational health and safety. In this posting I describe four of them.

Centre for Rehabilitation of the Paralyzed (CRP)

40 years ago while still East Pakistan, Valerie Taylor, an English physiotherapist, left to work at a leprosy hospital in the Chittagong Hill tracts with Voluntary Service Overseas (VSO). 10 years later, in 1979, she acted on the need she saw for assistance to the disabled, especially the paralyzed, by founding the Centre for Rehabilitation of the Paralyzed (CRP).

Today, the organization is one of the most well recognized and respected in Bangladesh, and has expanded to include over 100 beds, including some designed specially for the paralyzed (with mirrors and harnesses). It has a pediatric unit to train mothers to care for their children with cerebral palsy, with up to an eight month waiting list, and a school for children with cerebral palsy (often orphans) who are eventually integrated into regular schools. It offers physiotherapy and occupational therapy services to thousands of out-patients each year, and the newest addition is a department for speech therapy, including training of Bangladeshi speech therapists.

350 paraplegic and quadriplegic patients are admitted annually, some children, and often as a result of carrying heavy loads on their heads (sandbags, bricks, etc). Amazingly, all wheelchairs are made in a metal work shop on-site, specific to each patient, with rickshaw parts! Numerous ramps with various terrains have been constructed for the patients to practice so they can use the wheelchairs back in their villages. In fact, a halfway-house has been created with and without electricity, depending on the condition of the patients’ home village, for them to get used to before going home.

All prosthetics are made on site using casts and an oven to shape the plastic. There is also an independent living centre for disabled women, and a vocational training (sewing, electronic repairs, etc) centre so patients can learn income generating skills that can be performed while in their physical condition.

CRP attracts interns, professionals, and donors from all over the world. Valerie has been awarded the Order of the British Empire, the “Shadhinota Dibosh Podok”, Bangladesh’s highest civilian honour, and in 1998 she was made an honourary Bangladeshi citizen.

Centre for Corporate Accountability (CCA)

The Centre for Corporate Accountability (CCA) is a charity, promoting worker and public safety in Bangladesh. It was initially an organization in the UK, but executive director, David Bergman, set up the office in Dhaka in 2004. Its focus is on “the role of state bodies in enforcing health and safety law, investigating work-related deaths and injuries, and subjecting them to proper and appropriate prosecution scrutiny”.

Last year, working with Bangladesh Occupational Safety, Health and Environment Foundation (OSHE) and the Bangladesh Institute of Labour Studies (BILS), CCA published a report compiling worker deaths reported in the national Bengali and English newspapers in 2007. Results showed the majority of worker deaths were occurring in the construction sector, a contradiction from ILO estimates that state they are agricultural.

While I met David at a meeting arranged with WHO and OSHE (described in the next section), Valerie from CRP had also suggested I meet him; apparently CCA is investigating some work-related injuries from CRP, which could possibly lead to real compensated claims, a rarity in Bangladesh.

Bangladesh Occupational Safety, Health, and Environment Foundation (OSHE)

The Bangladesh Occupational Safety, Health, and Environment Foundation (OSHE) was established in 2003 to address issues affecting worker health and safety, income, employment, and overall livelihood. OSHE is a national collaborating center of the International Labour Organization.

My first encounter with OSHE was last year when Dr. Hugh Davies and I visited representatives in Chittagong, at one of the satellite clinics they had set up specifically for shipbreakers. I met with representatives again this visit at a meeting with WHO and CCA; this was a meeting to discuss their plans for future work resulting from the evidence of high fatalities in the construction industry from the CCA report on workplace fatalities.

Centre for Injury Prevention and Research, Bangladesh (CIPRB)

Finally, I went to visit a contact from my trip last year who is feeling more like an old friend now: Dr. Bennoor, a physician and assistant professor of respiratory medicine at the “National Institute of Diseases of the Chest and Hospital”, in Dhaka.  While telling him about my current project on occupational injury surveillance, he suggested another person I should meet.  Dr. Fazlur Rahman is the executive director of the Centre for Injury Prevention and Research, Bangladesh (CIPRB), and Dr. Bennoor arranged for me to meet him later that afternoon.

Dr. Rahman initiated this centre for injury research four years ago and they focus on preventing injuries in children, including child labourers. CIPRB has a very impressive surveillance system; they gather health and demographic information from 800,000 people: 200,000 in four areas (three rural, one urban; different from the ones I will be working with at ICDDR,B). 60 people are employed to gather information 4 times a year. They are finding that the major injury causing death in children is drowning, and have implemented swimming lesson programs for children aged 4-10 across the country.

Here I find myself once more, in this chaotic country I’ve grown to love, this time on the brink of monsoon rains. Although I’ve experienced nothing but blazing sun since I have arrived, the heavy humid air presses against my chest like a sheet of bricks and the skies threaten to open up, teetering on a dew point fulcrum. I hadn’t even stepped off the plane in Dhaka before I was reminded exactly where I had returned; on the tarmac were shirtless men in lungis (the sarong type garment worn by men) labouring away under floodlights into the sweaty night, possibly repairing one of the many runway potholes. The hair-raising drive into the city is always a sure way to become re-acquainted with the surroundings: weaving between colourfully painted trucks brimming with bricks, bananas, or garbage at break neck speeds, cutting through the thick black exhaust, and blaring horns the whole way, ahhh yes, music to my ears. By the time you make it to bed that first night, it feels as if you’ve run a marathon without ever having left the back seat. The mosquitoes were happy to see me again. Back home, a mosquito bites you once; around here, the persistent little buggers are perpetual plasma-sucking pests. That is, if one cunningly ends up in your mosquito net, like it did on my first night back, you had better find it and destroy it or you’ll wake up looking like you’ve contracted measles. I was recently informed mosquitoes prefer type B blood; most likely just another myth. Still, I do wonder why I seem to be targeted more than others. Calls to prayer at the break of dawn ushered me into my first morning back. The imam’s delivery can be hit or miss, but this morning, his mellifluous tones were especially beautiful. A week gone by now, I sleep right through the morning prayers, a sure sign I am well on my way to reintegration.

What am I doing here again, you ask. Well, last time I was here, September to December, 2008, I was conducting field work for my thesis study on “Prevalence of asbestosis in migrant shipbreakers from Northern Bangladesh”. While I am still working on my thesis, I have returned to Bangladesh to initiate another project; this time following up on some groundwork laid by Dr. Hugh Davies, on his last visit to Bangladesh in December. This project has to do with initiating a system of surveillance for occupational injuries.

In Bangladesh, occupationally-related morbidity and mortality are under-reported. Presently, injury information is not available in any organized form and there is no systematic collection of information on where occupational injuries are occurring, and what they are. The majority of the 65 million workers lives in rural areas in the agriculture sector with no formal industrial units; even if a system was in place to collect information, it would overlook a large portion of the population who fall outside the scope of national statistics systems.

I will be working with an organization known as the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) and their Health and Demographic Surveillance System. Today, ICDDR,B is an international health research institution that has evolved from being the “cholera hospital” back in 1960, to addressing a wide range of global health priorities and attracting researchers from all over the world. It is divided into five divisions, one of them being the Health Systems and Infectious Diseases Division. This division carries out community based research including two rural field stations: Mirsarai and Abhoynagar, and an urban station in Dhaka: Kamalapur. Part of their research involves the administration of the Health and Demographic Surveillance System survey to determine effectiveness of interventions such as vaccine trials.

It is by using this survey, we have proposed to incorporate a module of questions regarding occupational injuries. The questions are based from an International Labour Organization methods manual, “Occupational Injuries Statistics from Household and Establishment Surveys”, which were developed for use in countries where the traditional notification systems have restricted coverage in terms of workers, activities or types of injuries. The advantage of using a household survey is that it provides the possibility of obtaining information about people who would not normally be captured by a national statistical system. Questions and methodology have been pilot tested in Jamaica, Nigeria, and the Philippines, and will be modified to be appropriate for the Bangladeshi public.

I must say I am very pleased to be working with ICDDR,B. Of all my visits to Bangladesh, and all the organizations I have been involved with, they are one of the most professional and organized institutions, and it is clear why they are recognized the world over. Nevertheless, no matter how world class an organization is, it still suffers from some of the same problems as everywhere else: milk and sugar in my black coffee, irritating phone ring tones, overly freezing cold air conditioners, and power cuts at least six times a day, most likely due to the air conditioners! Ah well, it’s all part of the charm.

It is hard to believe that nearly four months has passed since I stepped off that plane at the Zia International Airport back in August. In some ways, it seems as if it was only yesterday, but in fact, enough time has now passed for the air to have chilled, for the mangoes to be long out of season, and for me to have completed my field work. Zakia and I interviewed 104 respondents; 104 names and faces whirl around in my mind and for the most part blend into one, but there are a few that seem to stand out and may forever be entrenched in my memory. My Bangladeshi experience was in stark contrast from my first visit here as a CIDA youth intern in 2006. The tremendous culture shock and isolation I felt back then will not be soon forgotten; in fact, I had to ask myself several times why on earth I was returning! This time, however, despite the expected shifting of gears right at the beginning, I felt as though I had warmed up to this country. Learning more of the language helped tremendously in situations that were previously frustrating, and often, when actions seemed irrational, there were logical reasons behind them (this was not always the case either, of course). I was much more at peace and I think in any kind of international work, this acclimatization is vital to be receptive and able to connect with the local people. Perhaps this can be said of any study, anywhere, but in such unfamiliar surroundings, it is important to allow yourself additional time to become acquainted with the country and its people before jumping straight in. Feeling as I did the first time would have made it far more challenging to work with Zakia and to obtain any insight into the lesser known industry of shipbreaking.

Dr. Hugh Davies visited Bangladesh this month for nearly two weeks. The purpose of his visit follows the three main ideas of this blog: Projects, Training, and Collaboration Opportunities. He observed Zakia and me conducting interviews in Bogra, attended a dozen meetings in Dhaka that spanned labour organizations to research institutions, and squeezed in a short trip to Chittagong as well. While his visit in April allowed him to get a general sense for occupational and environmental health research here and areas for growth, I believe this visit revealed many more specific avenues for future projects, training programs, and solid collaborators to start working on some proposals with immediately. In the new year, after sorting out the flurry of information, another entry could be dedicated to the various groups he met with, and what their areas of interest are.

On my last morning in Bogra, I was peddled through the little potholed streets on a rickshaw, while observing all the familiar morning rituals of shops opening, old men gossiping, and the flipping of chapattis in the roadside stalls. The sky was pink from the sunrise, the aroma of fried eggs lingered in the slightly chilled air, and I was momentarily overwhelmed with a sudden sadness. I took comfort in knowing all my goals for this portion of the study had been met, (that there are many months of data analysis and thesis writing ahead to remind me of this country that I have grown to love), and that this will, inshallah, not be my final farewell to Bangladesh.

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!!

Over a year of writing grant proposals, performing literature reviews, planning, networking, organizing, traveling to Bangladesh twice in the last year, and finally, enrolling subjects last week and again this week, had been all for this one moment: when the first subjects walked through the doors of the Mohammed Ali hospital in Bogra for their chest x-rays and interviews. My dream from two years ago of working on a project involving the shipbreaking industry was finally going to be a data collection reality and I could not have been more excited! However, there was one little problem.

They did not show up.

Monday revealed one of the largest hurdles I have hit so far. Hannan, the assistant health inspector, called that morning to inform me he had seen them off onto the correct bus at 7:30 am; the voyage should have been an hour and a half at the most, but hour after hour went by and once 12:30 rolled around, the harsh reality started to sink in that they would not be coming. This was followed by a feeling of dread that perhaps none of them would ever show up and I would be returning to Canada empty handed!

I believed the problem may have been confusion with bus connections, or simply a huge delay due to unreliable bus services in rural areas. I suggested to Hannan, that instead of seeing them off on a bus, they should be using something like a CNG (an autorickshaw) that would bring them directly to the hospital. I ran through countless scenarios in my head of what could have happened, but in the end, I knew I could only hope for a better turn out the next day, and perhaps using more direct transportation could help matters.

I arrived the next morning to find not only three subjects like expected, but four subjects; it turns out one man had been at the hospital that first morning but could not find us. This is impossible for me to fathom as the hospital is not large, most of the hospital staff are aware about me and what I am doing there, I was standing out front the entire time, and foreigners tend to stick out like a sore thumb in these settings. Anyhow, I was extremely pleased to see he had returned with this second group of subjects, and was still very keen on being a part of the study.

Apparently the other two no-shows had a change of heart because they thought I was going to give them vasectomies!!! Now, this just boggles my mind, but it was explained to me that there is a non-governmental organization (NGO) in town that provides people with some money and a free lungi (for men) or sari (for women), in exchange for a little operation, and because my monetary reimbursement for one day’s lost wages is the same amount, they, or some of their family members, confused me with this other organization. I am not sure if this means they are not listening during the reading of the consent form, or what this says about the meaning of “informed consent” here, and I am not entirely sure how to address this issue right now.

I had the opportunity to speak to these two men, who ended up coming to the hospital today after their colleagues assured them I was not sterilizing people. It sounds like they understood what was being asked of them at the time they provided consent, but afterward, family members started talking, someone in the village raised this point about the other NGO, and through an unfortunate series of conversations that rippled throughout the village, the entire message became skewed. I am not sure now if I have a better understanding of what happened, or if I am more confused than ever!

To end on a positive note, eight shipbreakers have now visited the hospital, had chest x-rays taken, and been interviewed. This part has proceeded smoothly and the hospital staff has been extremely accommodating. I can only hope this momentum can now be maintained and that there won’t be too many more surprises around the bend!