Discovering JiVitAland
The decade-long JiVitA project—one of the largest nutrition trials of its kind—has recruited 100,000 pregnant women and their babies with a grand goal in mind: Find new ways to save lives in South Asia.
The day is already hot in Bangladesh’s Rajshahi Division.The muezzins have long since announced the dawn prayer, and the blue sky frustrates the villagers’ hopes for the monsoon rains. A farmer drives a pair of white oxen along a road that bisects fields of rice and jute. A shirtless man strains to pedal a rickshaw van. A woman in an orange sari hangs laundry on a rope strung between palm trees.
As farmers and housewives begin daily routines that have remained constant for generations, 652 local women are starting a day’s work that is novel for Bangladeshi villagers: collecting public health data. Setting out on foot and by bicycle, they are instrumental in conducting one of the world’s largest community trials of the role of nutrition in maternal and infant survival. By the trial’s conclusion in 2011, these JiVitA Project workers will have recruited nearly 100,000 pregnant women and their babies.
The decade-long JiVitA Project comprises three main studies that have shared a common purpose: testing whether micronutrients will save the lives of mothers and babies in northwestern Bangladesh—and by extension, in other rural regions of South Asia. JiVitA (pronounced “jee-veetuh”) is a play on the Bangla word jibheetoh, or “alive.”
“Women die in childbirth at a much higher rate in South Asia than they do in developed countries,” says Parul Christian, DrPH ’96, MSc, MPH ’92, an investigator for all three trials and an associate professor of International Health at the Bloomberg School.
The project in Bangladesh grew out of a groundbreaking nutrition trial in Nepal that concluded in 1997. That trial, also led by School faculty, showed that giving vitamin A to pregnant women reduced maternal deaths by 44 percent overall. These remarkable results prompted researchers to wonder: Could vitamin A also improve survival in other parts of South Asia where malnutrition was widespread?
In the 11 years since the JiVitA Project started in Bangladesh, researchers have investigated the effect of vitamin A on maternal health (JiVitA-1) and infant health (JiVitA-2). The study now under way (JiVitA-3) is examining whether infants are more likely to survive if their mothers are given a daily multi-micronutrient supplement during pregnancy.
“We see great opportunities for public health approaches to improve health and reduce infant mortality in these vast rural settings of South Asia,” says JiVitA Project director Keith P. West, DrPH ’87, MPH ’79, RD, the George G. Graham Professor of Infant and Child Nutrition, who also led the earlier Nepal study.
Habib-ara, one of JiVitA’s 14 staff coordinators, thinks of generations to come as she supervises 60 field staff. (Like many women in Bangladesh, Habib-ara uses only one name.) “A healthy mother will give birth to a healthy child,” she says. “Today’s child will be a mother in the future.”
On this July morning, in week 448 of the JiVitA Project, field distributor Nur Banu is visiting a new baby. This “JiVitA baby” was born the previous afternoon in the village of Kamar Pachgachi, where Banu herself lives.
As one of the 596 field distributors—all of them female—Banu is assigned to find local women as soon as they become pregnant, recruit them to the study and then give them prenatal supplements. In addition, whenever a child is born, the field distributor doses the new baby with vitamin A. That task brings Banu here today.
She finds the newborn asleep in the family’s kitchen shed, lying on a bed of rags and straw. The child’s mother, Shahinoor, sits on a low stool beside the chubby-cheeked baby girl. The baby is Shahinoor’s fourth child, and she is not yet named. Shahinoor looks frail, her red cotton sari draped over her head.
Like 95 percent of JiVitA babies, this one was born at home. In keeping with village customs that regard childbirth as polluting, Shahinoor did not give birth in the family house, however. The combination kitchen shed and cow stall next to the house served as an atur ghar, or labor room. The shed has grass walls, a mud floor and a corrugated iron roof. Mother and daughter will remain there for three days. On the third day, a barber or someone else chosen by the family will shave the baby’s hair, which is considered unclean. Then Shahinoor will return to her house, and her newborn daughter will enter it for the first time.
Banu greets the new mother and unpacks her supplies just inside the shed door. She has been here dozens of times. She began visiting JiVitA household #0049 even before Shahinoor became pregnant with this child; as a married woman of childbearing age, Shahinoor was a candidate for the study and has been among the local women Banu regularly visits in her search for pregnant women.
In December, Shahinoor told Banu that she’d missed her period. Banu tested her urine to confirm the pregnancy and invited Shahinoor to take part in JiVitA-3. Like 98 percent of women asked to participate, Shahinoor consented. Since then Banu has visited Shahinoor twice a week to remind her to take the daily supplements, to record how often she has done so, and to refill her supply. By the trial’s end, Banu and her co-workers will have followed 36,000 pregnant women to measure the effects of multiple micronutrients on infant mortality and morbidity.
Because the trial is blinded and randomized, Banu doesn’t know if the red tablets she gives Shahinoor contain the 15 nutrients or an iron and folic acid supplement that meets the WHO standard of care.
Today Banu is accompanied by two other women. One is interviewer Lovely Rani Mondol, who will ask Shahinoor about the birth. The other is researcher Parul Christian, who is visiting from Baltimore for two weeks.
Christian has visited the JiVitA Project so many times that she’s lost count, and by now her Bangla is pretty good. She can follow most of what goes on as she crouches in one corner of the atur ghar watching Banu at work.
Banu squats beside the newborn. She uses scissors to snip off the end of the vitamin A capsule, and she deftly squeezes the contents into the baby’s mouth. The baby grimaces, then cries and turns red. With this first taste of something other than milk, the child is benefiting from what researchers discovered in the JiVitA-2 study. In that trial, all JiVitA newborns were given either 50,000 IUs of vitamin A or a placebo.
At any given time, each field distributor is monitoring about 200 women of childbearing age. Each month, the distributors supply vitamins to about 8,000 pregnant women. And on an average day in Jivitaland, those women give birth to 29 babies.
Led by assistant scientist Rolf Klemm, DrPH ’02, MPH ’85, field staff dosed 16,000 newborns. Klemm and colleagues reported the results in the July 2008 Pediatrics: A single two-cent dose of vitamin A cut six-month death rates by 15 percent. Now all JiVitA babies get vitamin A soon after birth.
Standing in the doorway of the house, the baby’s grandmother silently watches the scene. From her point of view, her son and his wife must seem fortunate, for they have never lost a child. Of the grandmother’s eight children, four died in infancy. She lost three boys and a girl.
On a conventional map, JiVitA territory stretches across the sector of northwestern Bangladesh called Gaibandha District and nips into Rangpur District. To the research team, this is “Jivitaland.”
Jivitaland requires its own map. No ordinary map would show Shahinoor’s house in Kamar Pachgachi. The red number 0049 painted on the corrugated iron near the front door signifies her home’s inclusion on an extraordinary digital map, one that records the location of every one of 145,000 households in the JiVitA study area.To create it, 64 survey teams walked the entire project territory—270 square miles. They validated and augmented information on 1930s-era paper maps drafted by the British during the colonial era. They assigned a number to each household, or khana, “those who eat rice from the same cooking pot.” Nine years later, fieldworkers carry bottles of red paint to touch up faded numbers
Funding comes from the Gates Foundation, USAID, the Sight and Life Research Institute in Baltimore and the Micronutrient Initiative of Canada’s international development agency.
It’s a big undertaking: At any given time, each field distributor is monitoring about 200 women of childbearing age. Each month, the distributors supply vitamins to about 8,000 pregnant women. And on an average day in Jivitaland, those women give birth to 29 babies.
Christian and West hadn’t expected to do this research in Bangladesh, but rather in India, where Christian grew up. But in 1998, when they looked at governmental and NGO data for the Gaibandha area of Bangladesh, they found pervasive signs of malnutrition.
Anemia rates for women of reproductive age were 46 percent. More than half the children were stunted. These signs suggested that rates of malnutrition were similar to those in other impoverished regions of rural South Asia.
Furthermore, recalls Christian, in Bangladesh “we found the right spirit of collaboration,” in particular with the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies. And it was through the director of that Institute—West’s Hopkins classmate Halida Akhter, DrPH ’82, MPH ’79—that West met the physician who would become the first of their Bangladeshi research partners, Mahbubur Rashid, MBBS, PhD, MSc. As Rashid recalls, “Keith did a five-minute rapid assessment, and from then on I was with them, every minute—with no time for sleeping.” Rashid is now the project’s medical epidemiologist and a member of senior management.
That was in 2000. Soon after, the project hired a core staff of 80. They laid the groundwork for the project by convening community information sessions in rural villages and meeting with government leaders, journalists, school principals and clergy, both Muslim and Hindu.
Good community relationships would provide the foundation for this large study, but only good data would ensure its scientific value. Rashid jokes that West was so intent on gathering consistent data that he would have liked a single person to do it all. As Rashid puts it, “Data collection should be as faithful as a photograph in creating a picture of public health.” And so training for field staff in 2001 was extensive: three months, full-time, for the 596 field distributors; and nine months, full-time, for 56 female interviewers who also do anthropometry (physical measurements) of mothers and infants.
Christian told the trainees: “You need to treat data as representing real lives. The data are not just numbers, they’re telling us a story about the life of an individual.” Without an accurate depiction of those life stories, she told them, “You’re not going to get the right answers to the research questions.”
On this July morning, precision is Christian’s chief concern as she watches Banu and interviewer Mondol at work. By witnessing data collection, Christian says, “I can observe how accurately it’s being done and whether protocols are being followed.”
The project’s findings on infant vitamin A could provide the impetus for national policy: Widely distributing vitamin A to newborns could cut infant deaths by 20 percent in Bangladesh and elsewhere in the region.
Being female provides latitude for Christian as a researcher. Women in South Asia are unlikely to discuss the intimate topic of reproductive health with men in the room, and following a birth, taboos require male researchers to keep their distance.
“As a female, I have the advantage of being able to do some of the direct observation, which is not as possible for Keith and Alain,” says Christian, referring to West and assistant professor Alain Labrique, PhD ’07, MS, MHS ’99. Labrique, an expert on health and society in Bangladesh, served as the Hopkins Project Scientist in-country for seven years.
Mondol is kneeling beside the newborn, measuring her head, when the baby’s father arrives home for lunch. Rezaul Alam is barefoot, his cotton lungi (sarong) splattered with mud. Alam has spent the morning drying jute grown on the family’s quarter acre. He glances toward the kitchen shed, then escapes the glare of the sun as he enters the family’s one-room house. He sits on one of the two beds. Besides farming, Alam sells jute seeds, and the cotton bedcover is made of seed sacks sewn together.
Alam says that he and his wife had not planned for a fourth child, “but as Allah gave her to us… .” He does not complete the sentence, but he looks content. He wraps his arm around the younger of his two sons, Mominul Islam, whom his father estimates to be “maybe 5 years old.” Alam thinks that he and his wife are about 25 years old. (Few village residents can confidently say how old they are. “How can we know our age?” asked one woman with amusement.)
Shahinoor and Alam’s oldest child honors the visitors by offering a tray of paan—chopped areca nuts, green betel leaves for wrapping around them, and powdered lime. At 11, Sajeda is young enough that she does not yet have to wear a sari or a complete salwar kameez (loose pants and a knee-length tunic worn with a long scarf). Instead she wears a yellow tunic over shorts, more comfortable on a day with temperatures in the low 100s.
Unlike her mother, who never learned to read, Sajeda goes to school. She is cheerful and confident, with a short haircut that accentuates her bright eyes. She tells her father: “We should name the baby Renu.” He nods but makes no promises.
The grandmother watches from the courtyard as Shahinoor cradles her newborn; the baby is peaceful again after the annoyance of swallowing vitamin A.
Mondol is kneeling beside the newborn, measuring her head, when the baby’s father arrives home for lunch. Rezaul Alam is barefoot, his cotton lungi (sarong) splattered with mud. Alam has spent the morning drying jute grown on the family’s quarter acre.
In rural areas, most babies are born at home and without a health care professional attending. In Jivitaland, only 8 percent of women gave birth attended by a nurse-midwife or doctor. Half the women had help only from relatives or neighbors, or they gave birth alone.
He glances toward the kitchen shed, then escapes the glare of the sun as he enters the family’s one-room house. He sits on one of the two beds. Besides farming, Alam sells jute seeds, and the cotton bedcover is made of seed sacks sewn together.
Alam says that he and his wife had not planned for a fourth child, “but as Allah gave her to us… .” He does not complete the sentence, but he looks content. He wraps his arm around the younger of his two sons, Mominul Islam, whom his father estimates to be “maybe 5 years old.” Alam thinks that he and his wife are about 25 years old. (Few village residents can confidently say how old they are. “How can we know our age?” asked one woman with amusement.)
Shahinoor and Alam’s oldest child honors the visitors by offering a tray of paan—chopped areca nuts, green betel leaves for wrapping around them, and powdered lime. At 11, Sajeda is young enough that she does not yet have to wear a sari or a complete salwar kameez(loose pants and a knee-length tunic worn with a long scarf). Instead she wears a yellow tunic over shorts, more comfortable on a day with temperatures in the low 100s.
Unlike her mother, who never learned to read, Sajeda goes to school. She is cheerful and confident, with a short haircut that accentuates her bright eyes. She tells her father: “We should name the baby Renu.” He nods but makes no promises.
The grandmother watches from the courtyard as Shahinoor cradles her newborn; the baby is peaceful again after the annoyance of swallowing vitamin A.
For Christian, a visit to Bangladesh means hours and hours in meetings. On this sweltering afternoon, she sits under the ceiling fans in the conference room of the project’s four-story office building in the town of Gaibandha.
A dozen senior staff members are discussing a JiVitA-3 sub-study that seeks to understand the movement of micronutrients from mother to fetus. To do this, six nurse-midwives will soon begin attending births, sampling umbilical cord blood and weighing placentas immediately after delivery.
This afternoon’s scientific task is to agree on standardized conditions under which the midwives will refer mothers and newborns to emergency care. The administrative issue: how much to pay the midwives for 24-hour on-call duties. The group arrives at all decisions by consensus.
Between field visits and meetings, sometimes late at night, Christian confers with graduate students working on the project—three at the moment. To keep morale high, she’s brought them a box of Lindt chocolates. She says, “I feel that they’re being deprived when they’re just eating a dal-bhat meal [lentil gruel and rice]. They’re probably craving chocolate.” Good chocolate is scarce in Bangladesh, but there are compensations: During afternoon meetings, the head cook arrives in the conference room with plates of luscious local mangoes and cups of sweet tea.
The Gaibandha office building is home base for many of the project’s 180 scientific, supervisory, logistics and administrative staff. Among others, they include 15 people who enter data, six physicians, four translators, two cooks and a mechanic to look after the project’s 53 motorcycles.
The tremendous organizational feat that has made JiVitA possible could bear fruit in at least two ways.
First, the project’s findings on infant vitamin A could lead to national policy: widely distributing vitamin A to newborns could cut infant deaths by 20 percent in Bangladesh and elsewhere in the region. Already, senior JiVitA researchers have spread the news about the effects of infant vitamin A at 15 presentations to Bangladeshi government officials and groups of doctors.
The next step is to figure out how to deliver the vitamin A to newborns beyond the study area. This poses huge logistical challenges. In rural areas, most babies are born at home and without a health care professional attending. A survey in the JiVitA Project area, for instance, found that only 8 percent of women gave birth attended by a nurse-midwife or doctor. Half the women had help only from relatives or neighbors, or they gave birth alone.
Bangladesh’s Ministry of Health is close to granting permission to JiVitA to begin operations research into how to broadly distribute the vitamin to newborns, says Rashid.
The second legacy of JiVitA may be the research site itself, providing more opportunities for research in Jivitaland, home to 650,000 people. It’s unclear what might come next, but West, Christian and Labrique all have proposals in the works for further studies in maternal and child health.
Rashid feels confident that scientists will continue to come, whether from Hopkins or elsewhere. “The infrastructure is here,” he says, “so the cost would be minimal to continue research. We have a huge cohort of the population. We have detailed maps, GIS maps, of this population, and trained manpower—womanpower, human power. ... It’s a diamond mine. We just need some good research questions.”
Christian says, “Our biggest challenge is to continue to sustain the big population site that we have spent so much time and effort developing. Our Bangla staff feels a strong sense of ownership.”
In the village of Sahabaz, in one of the 145,000 households in Jivitaland, a baby boy sleeps aloft: his small bed is suspended from a bamboo rafter by jute ropes and decorated with colorful ribbons.
Interviewer Ripu Rani has come to see the month-old child and his mother, Asiya. Rani will ask Asiya a series of standardized questions about her son’s first month of life and about Asiya’s own health during her final month of pregnancy and the month since the birth. This is one of six or seven interviews that Rani will do today, traveling by bicycle.
Asiya’s child continues to sleep as Rani unpacks bulky bags of equipment, including adult and infant scales and a board for measuring the length of infants, designed and built by the JiVitA Project.
Rani first met Asiya a few days after a field distributor confirmed her pregnancy. At that first meeting, Rani asked Asiya baseline questions about her health, her diet, her work history and her socioeconomic status. She learned then that like many villagers, Asiya’s family owns no land. Her husband earns money as a farm laborer, and Asiya raises poultry: two chickens and four ducks.
Today, Rani weighs the baby, now awake and crying piteously, and she measures his upper arm, chest, head and length.
Sooner or later, field staff like Rani will inevitably face the death of a participant’s child. One of Rani’s colleagues, field distributor Selina, comforts the mother this way: “I try to make her understand that the baby came from Allah. It’s the will of God—that’s why the baby’s dead. Any of us can go at any time.”
Such painful conversations are rare for Selina. “I feel valued,” she says. “I hope JiVitA will continue to run. I can work with it, and I can survive. For physician and epidemiologist Rashid, working for JiVitA not only allows him to earn a living, but also to serve humanity.
“I think this is the motivation for all of JiVitA,” he says. “Doing good for people in need and serving them is a sort of prayer.””