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.

It is hard to believe it has only been about a week since I arrived. Not only has a lot happened, but a lot has changed. The need for flexibility and adaptability while working here is an absolute must.

I suppose the first big change was when my project did a complete 180˚ turn back in April. It was originally meant to be an exposure assessment study of asbestos fibres in the communities surrounding the shipbreaking yards in Chittagong, a bustling southern port city. During a feasibility trip in April, I ran up against a few barriers, the greatest being the shipyard managers’ distrust of foreigners. Although the exposure assessment was not meant to take place in the yards, rather, the in communities surrounding the yards, the yard managers’ influence extended into these communities and it was clear we were not welcome. The study at this point took on a new shape. It became a health outcome study of asbestosis in migrant shipbreakers who had returned to their home communities of Bogra, an impoverished, rural, northern district in Bangladesh. I was very pleased with the outcome and realized how important this two week trip in April had been. We met key people such as the Bogra district civil surgeon, the district’s top health official, and without it, I can only imagine how far I would be set back on this trip, although this trip has not been without its barriers either.
The plan was to head up to Bogra after a couple of days in Dhaka for the field work which would take approximately three months (Sept-Nov), and spend the last month (Dec) in Dhaka to introduce bulk asbestos identification to faculty and students at NIPSOM. We realized I would be starting the field work towards the end of the wet season, and at the beginning of the holy month of Ramadan, but so far there had been no major floods up north and although people fast during Ramadan, working-life continues and so it was not perceived to be a huge problem.

The day I left Vancouver, Bihar, a region of India right by northwestern Bangladesh where I was to go, experienced some of the worst flooding in 50 years. Quite a bit of the excess water, inevitably, flowed into Bangladesh and I had to face the reality that it would affect my study location, situated on the banks of the Jamuna River (a branch of the mighty Brahmaputra River). Already, a couple of days on Bangladeshi soil and we needed to do some serious rearranging. The main worry was that even if flooding was not severe, people would scatter in anticipation of floods and I would not be able to locate them. I decided not to leave for Bogra right away, and my worst worries were confirmed when a flood control dam was breached and hundreds became homeless.

Flooding is a regular occurrence in Bangladesh, a major delta, and news of it makes headlines, but it doesn’t come as a shock to anyone. All I was advised to not worry, that “This is not like Katrina”, and just to wait it out a bit; all should be dry and back to normal in a few weeks. Consequently, I have moved the asbestos identification training up to the first few weeks here in Dhaka, and my field work in Bogra has been shifted to October right after the Eid holiday, which marks the end of Ramadan.

This now leaves me 10 weeks in Bogra to enroll and interview 100 respondents (see bottom of entry for note on terminology), and no more wiggle room at the end. Otherwise, this was a smart decision. Beginning the field work mid-October means better weather, but also, it coincides with the Aman (wet season) rice harvest, one of three yearly rice harvests, which means most people will be home. Finally, Ramadan will have passed, meaning less hungry respondents who have just finished celebrating Eid, which is kind of like getting together for Christmas.

As I look around me and see Ramadan just kicking into full swing, my field work seems far away. There is always more to prepare, however, and this allows me more time to ensure translations are appropriate for both the consent form and questionnaire, and a chance to pilot test the questionnaire as well.

With that I will end with one of my favourite sayings, something I picked up in Turkey, but because it is an Islamic saying, used in Bangladesh as well. “Inshallah”, or “God willing”. It is used just about all the time, in any situation you find yourself in where you just throw up your arms in defeat and realize that sometimes things are beyond your control and you just have to go with the flow……..

Note: The term “enroll” is used instead of recruit because in Bangladesh, recruit is a term used for men who are selected to work as migrant labourers overseas. Using the term recruit can lead to confusion about my purpose here. “Respondents” is used instead of subjects, as that is the norm for researchers in Bangladesh.

Sitting here jet-lagged and watching TV at 3 in the morning, I never realized Tim Allen and Jonathan Taylor Thomas were fluent in Hindi. Although Bangla is the language spoken in Bangladesh, most of their TV programming is Indian, and so Hindi is heard most frequently. I guess it is similar to how in Canada, we see mostly American programming. Fortunately they speak the same language as us, for the most part.

Despite a few hurdles along the way, such as my visa showing up the day before I was to leave, and typhoon Nuri delaying my arrival by a few days, I finally made it to Dhaka. Upon landing, I was greeted with a blast of humidity. It seemed to seep right through the walls of the plane even as we waited to exit. Stepping out into the hot Dhaka night, I looked around, remembering the anxiety I felt my first time landing in Dhaka back in 2006; I saw the grimy metal bars, holding off people with their hands sticking through, the chaos of taxis and sounds, but this time, I felt a certain familiarity, as if maybe I am finally starting to get used to this country.
My hotel room overlooks Gulshan lake, a murky lake with mysterious black blobs that seem to swirl up from the lake bed, and saturated with fish, although I see nobody fishing. Apparently about twice a year chemicals are dumped into the lake to cull the fish and belly-up they go, coating the surface. I was watching the pouring rain beat down onto the water, trying to work up enough nerve to get up and go to NIPSOM, the university I will be working with. It always takes a little coaxing to get myself out onto the chaotic streets, kind of like jumping into a cold pool; you know you will warm up as soon as you jump in and start swimming, but the hardest part is just getting in!

Once at NIPSOM, I found Dr. Akhtar pretty easily. My supervisor, Hugh, and I had met with him about three times during our last trip. He has a big round happy face and smiles all the time. He dies his hair with henna (this plant Indian people use to die patterns on their hands and also their hair) so it is a bright red, and he speaks with a husky, whispering voice, as if he were the godfather. When my appointed research assistant, Zakia walked into Dr. Akhtar’s office that morning, I liked her instantly. She had a friendly smile and exuded positive energy. We went off to talk about the details of the project and I found her to be sharp, awake, and to have a good sense of humour. Unfortunately she has exams until the middle of September, so Zakia and Dr. Akhtar have selected someone else to come with me to Bogra for the first few weeks.

I made a decision this time to try as hard as possible to do things the local way, and not force anything the way I am used to, “the Canadian way”. For example, when working here back in 2006 with another organization, I tried to rush social pleasantries and force instructions to get right to work. I didn’t like how slow every process had to be and I realize now I was being impatient. I would try to clear up all ambiguities by repeating things over and over again. I found in the end this didn’t work at all; no matter how much I tried to speed up meetings, they were often slower than I expected, and no matter how many times I repeated things, there were still misunderstandings. I decided this time, just to sit back, practice a little more patience, and allow things to happen the Bangladeshi way. So Dr. Akhtar led the conversation, I waited for cues to speak or change the subject, and I was happy to find, we discussed almost everything I wanted to talk about that first day.

The microscope I dragged all the way from Canada has been delivered undamaged to NIPSOM after a hair-raising CNG ride (CNG stands for compressed natural gas, and is what people call the auto-rickshaws that use this fuel); I used one hand to make sure the scope didn’t fly out, and the other to make sure I didn’t fly out! Now only one more day here in the capital and then it is off to Bogra District to begin preparations for the field work.