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!

Well this was one of my most interesting weekends in Bangladesh. It started off with an invite to a festival known as the Lalon Shah festival in a town west of Dhaka; a musical festival that conjured up images of Sufis, sitars, and dancing barefoot. The two backpackers I met on the nightmarish Biman flight had befriended some members of the more Bohemian art community in Dhaka, and invited me to come along with them. They told me there may be some filming involved, but when I agreed to go, I had no idea what I was actually in stall for. Lights, camera, action – the whole shebang! Somehow I ended up being cast in a film about the legendary Lalon Shah himself, the festival held every year in his honour, and least but not least, a film that will be entered into the Cannes film festival!Briefly, Lalon Shah was a Bangladeshi philosopher who expressed himself through poems, songs and simple instruments. He completely rejected all notions of caste and creed, and lived a simple life in Bangladesh until the late 1890’s. He is credited with being one of the greatest influences for generations of Bangldeshi poets, artists, and musicians, including Rabindranathth Tagore. Tagore is quoted as saying in his Hebart Lecture in London in 1933, that Lalon Shah was a mystic poet who discovered “soul” and the meaning of “man”.

The festival itself is a little Bangladeshi Glastonbury (perhaps that is a bit of an exaggeration) but instead of mainstream pop stars, the musicians here are Bauls, a group of mystic minstrels that were first recorded as being in Bangladesh from the 1500’s. They gather here from all over Bangladesh to sing and play Lalon songs, filled with messages of peace and tranquility.

The film, called, “Ondhonirangom”, or, “The unread”, is about Lalon Shah, the story of his life, his music and his philosophies. It takes place against a broader backdrop of a group of foreigners who travel to the festival by train and learn about this mysterious man. That was where I, along with six other foreigners fit in. Shooting the first day took all day and started at about 6 am when I was picked up by the crew. We all piled on a local train to Kushtia, Khulna Division, on a journey that was to take about 6 hours from Dhaka. We were instructed where to sit, and fed a breakfast of chapattis and egg, while the crew got ready setting up lights, tracks down the aisle for the camera, and white Styrofoam reflectors.

There was much excitement as local travelers sat amongst us and of course stared even more intently than usual. When the train made stops, we would have to “cut” and wait for hawkers to walk through selling peanuts, biscuits and tea, then “action” once more as soon as the train crawled to a start. I had a few lines in the movie and I also have to get up and walk to some Baul minstrels and “pretend to enjoy” by swaying to their music!

Filming continued off the train as the camera men became really creative in order to take shots of us in local “Mossiman” (larger auto rickshaw) transport. There was a lot of stopping, starting, and backtracking, and being piled into this little vehicle in the middle of the hot cloudless day, was becoming quite frustrating. At some points the camera man was dangling off the back of the Mossiman, tied to it by three lungis (cloth saris worn by men), sometimes he was riding behind in a motorcycle, riding in front in a van, and once he even attached his camera to a piece of wood which stuck out in front of the Mossiman!

The crew really looked after us; all meals, hotel and transportation were taken care of. They even paid for me to get back to Bogra straight after the shoot the next day.

In the evening we finally entered the sacred festival grounds where Lalon Shah’s mausoleum is located. It was dark by then, and we were at once surrounded by people and music from all directions. The Baul musicians were in white robes and had either an ektara (instrument with a single string) or a dugdugi (small drum). Filming was challenging here with hundreds of spectators more interested in the “bideshi’s” (foreigners) than what they came for. After being groped more than a few times, I was relieved for the shooting to be over for the day! It is unfortunate sometimes to be a foreign woman in Bangladesh. The music and the musicians were phenomenal and I wished so much I could blend in to enjoy the performance for a while longer.

The following day turned out to be far better for enjoying the musical festivities. In the bright light of day, people left us alone a little more and we were able to fully appreciate the music of the Bauls, and the spirit of Lalon Shah that lives on through them.

I am finally in the field! My first day for enrollment went fairly smoothly, and with a few things to watch out for, I think I will be right on track. On Sunday (which is the first working day in Bangladesh, Friday and Saturday being the weekend), Dr. Akhtar arranged a WHO vehicle to take us, including Zakia my research assistant, up to Bogra. In fact, another man accompanied us, Dr. Salamat, whom Hugh and I know from a meeting with Andrew Trevitt of WHO, during our visit to Bangladesh in April. As it turns out, Dr. Salamat is also Zakia’s maternal uncle!

We went straight to the office of the civil surgeon, Dr. Nahar, where we met with Hannan (the assistant health inspector who did the baseline survey of shipbreakers in Sariakandi this past summer). We discussed the logistics of where and when we will meet each week for enrollment of subjects, and how we will instruct the subjects to meet us in Bogra city for interviews, etc. This is not as easy a task as it should be as there is always quite a bit of ambiguity in the answers to what I think are clear and straight forward questions. Also, there are always people coming in and out of the office, distracting Dr. Nahar for signatures; no meeting can ever go uninterrupted every two seconds! After some frustration and repetition of questions, I was generally satisfied with the answers, and you reach a point where you have to wait and see what happens. No matter how much you prepare, things will always change later on anyways! In fact, Zakia’s uncle was far more clear and helpful than anyone else and I was grateful for him being there. Maybe by working with Andrew Trevitt all the time, he understands the kind of clarity us foreigners seem to crave!

Next morning we left for Sariakandi town (the main town of the region of the same name where the shipbreakers are located in little villages) and I was under the impression we were just visiting the Sariakandi Health Complex to meet the Sariakandi region health officer, Dr. Emdad, before Dr. Akhtar and Zakia’s uncle left us to return to Dhaka. I thought we had the rest of this week to start enrollment of subjects for interviews the following week. But then, surprise again, we ended up at a village, where we were to begin enrollment right away, and I was a little frustrated because I was not exactly mentally prepared. However, I did have all my materials with me, although I needed copies of the Bangla consent forms, a process that ended up taking 2 hours; Dr. Akhtar had wanted to be there for the first subject enrollment but could not wait that long, so they returned to Dhaka, while Zakia, Hannan and I remained behind.

This is not exactly how I had envisioned my first day of enrollment. If you remember there are six different job groups in shipbreaking: Loaders, cutters, fitters, wire/cable pullers, hammerers, oil group. Loaders are the most frequent and I wanted to go to villages with shipbreakers with other than loaders first, but we ended up in two towns, both with only loaders. In fact, with the baseline survey of shipbreakers Hannan prepared for me, with over 200 names, including their village, job group and first year of work, I have a basic enrollment strategy planned, and I found myself already having to change around these plans. Like I said before though, working here, you really have to learn to be flexible.

Well, perhaps this was better for this first week, while we test out how appointments, interviews and x-rays work out at the hospital next week. I have already let Hannan know where I which villages and people I would like to target for enrollment next week. One idea I discussed with my committee was to go first to villages with job groups other than loaders and try to find more. My only worry with this now, and why it may be wise to stick to the original list of 200 people Hannan recorded, is because at that point there was no mention of reimbursement money. Now, after today, they know because of having the consent form read to them that there will be reimbursements and travel costs, and word will spread like wildfire. So perhaps it is better to stick to enrolling those already on the list only, and not look for new people at this point, even if it means most of my data will only come from the Loader group.

While Zakia is a physician and will be very helpful I am sure at the hospital in Bogra when it comes time for interviews, x-rays and physical exams, Hannan, is amazing in the field! Dr. Akhtar thought it would be best for him, instead of Zakia, to read the consent form to the subjects as Hannan knows how to get the message across better, and he works in this area frequently. Even while we were getting organized, he was not wasting any time; he was instructing all the curious visitors gathered around about the importance of tetanus vaccination especially for women, measles, and TB vaccinations. Once I was ready, he read out the consent form and I followed along with my English version and it sounded like he stuck to what was written exactly. He took the initiative to come prepared with referral cards he made up the night before so the subjects know exactly when to show up and where, and has promised it will be his responsibility to make sure they go. The chain of command out in the villages is impressive, with about 30 health assistants working for Hannan, each health assistant is responsible for health services for 4-5000 villagers. The husband of the health assistant for the villages we were in today, accompanied us all day.

We ended up enrolling 9 people from the first village, Bibirpara, and another 3 people from the second village, Haorakhali. They were provided with referral cards for visits to the hospital over four days next week. I will try to stick to enrolling in Sariakandi on Sundays, and then seeing subjects in the Bogra District hospital on Mondays-Thursdays.

It is difficult to explain the chaos that occurs in these otherwise peaceful villages during enrollment. Every villager comes out to see what is going on; it is quite impossible to get the shipbreakers completely on their own. Kids are crying, villagers are yelling, people are pushing and inching their way towards the centre where we are. Every once in a while someone will yell and push everyone back to try and give us some space again, but instantly the crowd starts inching their way forward again.
However, this is fine, of course I expected it, and I loved it, being in the field finally! Enrolling subjects amongst green paddy fields, walking through them to get from one village to the next, taking a rickshaw van to another spot; recruiting in a rickshaw van just how I imagined! By the way, a “van” in Bangladesh is not a vehicle with sliding doors. It is a flat wooden platform on wheels, peddled about like a rickshaw. You simply sit on the platform. The rickshaw driver asked if I was Saudi Arabian or Malaysian. Zakia told him neither; why did he only ask those two countries? He replied, because they were the only two countries he had ever heard of. Well, now he has heard of Canada.

Over Eid vacation, I went on a 10 day trek to Annapurna Base Camp in Nepal. Weather was perfect, company was excellent, and being the very start of trekking season, we ran into only a handful of other trekkers. For anyone who has climbed the Grouse Grind in Vancouver, imagine doing that, up and down, five times a day, for 10 days, and you will have an idea of what I did. Sounds grueling, but with views of lush green terraces, enchanted forests, a myriad of waterfalls, and of course some of the world’s most spectacular peaks, you almost don’t notice the burn in the legs. That is, until you realize you can’t move them to get out of your sleeping bag the next morning. Looking forward to a nice cold Everest beer at the end of the day wasn’t a bad motivator either. But what I really want to talk about is the journey home to Bangladesh from Nepal.On October 8th, at 9:00 am, I boarded a Yeti Airlines flight going from Pokhara (the starting point for most treks in the Annapurna region) to Kathmandu. From there I was to transfer to a Biman (Bangladesh Airlines) flight back to Dhaka. Well upon landing in Kathmandu, we learned that a Yeti Air flight going from Kathmandu to Lukla (the starting point for most excursions to Everest) had crashed killing all on board but the pilot. Lukla is a small airport with a 60 ft wide runway set on a slope, and a 2100 ft drop at one end. It was actually built in the 1960s by Sir Edmund Hillary to facilitate expeditions to Everest.

With this knowledge fresh on my mind, I embarked on one of the scariest plane rides of my life! Biman has a reputation for being unreliable, disorganized, and not necessarily dangerous, but everyone I know who has flown on it has a story to tell. Well I can honestly say I thought I wasn’t going to live to tell any story, but here it is.

Of course boarding the aircraft, I found someone in my seat, which was pretty predictable. I asked where I should sit and the flight attendants just kept saying, “free seating, free seating”. This means, sit wherever there is one available basically. I had run into two backpackers, a rare sight in Bangladesh, and we found three seats together in the middle of the plane. I think the most unnerving thing for me on a Biman flight right at the beginning is the announcement. All plane announcements are pretty much the same: estimated flight duration, arrival time, weather at destination, etc. Biman announcements end in, “inshallah”, which I think I have mentioned before, means, “god-willing”. I would really rather not leave my fate in the air in the hands of god, but I guess that is just a personal preference!!

I am not sure if taking off from Kathmandu airport is a little different from other airports in that there are some of the world’s highest mountains an arm’s reach away, but for whatever reason, when we took off, the plane went from horizontal to vertical in a matter of seconds; I could have sworn I was in a rocket blasting off, not in an airplane with the gradual ascent I am accustomed to. It didn’t end there. The turbulence was some of the worst I have ever experienced with the plane just dropping out of the sky over and over again; there were people screaming as if it was an amusement park ride and even the flight attendants were white knuckled and pale faced. The best part though, was landing in Dhaka. It was not a gradual decent. The plane was coming in fast and furious, and what looked to me like an odd angle. We were teetering back and forth so much I was seeing Dhaka to the left of me, then to the right of me, over and over again. I was clenching my teeth and saying goodbye to my family just in case, and just seconds before touch down, I look out one of the windows and I can see the tarmac. I am praying for a safe landing, and what happens next? Well, there is a huge shift in momentum, and back into the air we go!!!!

Landing had been aborted, perhaps we had overshot the runway, coming in too fast, I don’t know. All I knew was the feeling of dread in the bottom of my stomach that I was never going to make it off this plane. A couple of Bangladeshi passengers actually got out of their seat at this point in confusion and started to walk about the cabin! The backpackers next to me, I think, were enjoying themselves! But then you have to have some nerve to couch-surf in Dhaka to begin with. The Irish one sitting next to me let me hold his hand for the second attempt at landing. Meanwhile, the Bangladeshi man next to me was asking me why I was on this flight. Didn’t I know Bangladeshi pilots are inexperienced? Didn’t I know all their planes are refurbished, recycled, old planes from other carriers that no longer deemed them to be safe? Those words of comfort were just what I needed to hear at that moment.

Well I am here writing this entry, so I guess it means we finally landed. Apparently, the first attempt was aborted because there are two indicators in the cockpit to signal the wheels are fit for landing; one was indicating to land, and the other was indicating not to land. In a split second decision the pilots decided against landing, but I have no idea what they did to “fix” the wheel situation. Perhaps it is best not to know.

In fact other Biman stories make mine pale in comparison. I would choose my flight experience over the one a few weeks back where all the oxygen masks fell out of the ceiling, or the one where people lit up their gas cooker and started cooking on the flight, or even the one where a passenger lit a pipe in the back of the plane and when someone complained, they were reassured it was alright, because he is the pilot and the pilot is allowed to smoke….but who was flying the plane? Everyone is allowed one bad Biman experience in their lives, but I think one is enough.

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.