Photos by Saikat Mojumder

Discovering JiVitAland (continued)

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.