Voices from the Field
By Bono Sen
This month, Bono Sen, Program Coordinator for Global Environmental Health, NIEHS, asked David Christiani, M.D., M.P.H., of Harvard T.H. Chan School of Public Health, Quazi Quamruzzaman, M.D., of the Dhaka Community Hospital Trust (DCHT), Dhaka, Bangladesh, and Molly Kile, Sc.D. of Oregon State University to share the story of their efforts in building a sustainable community-based research practice in Bangladesh.
Building sustainable research capacity is important for developing and implementing evidence-based practice and policy solutions to address urgent environmental health needs in resource-limited countries around the world. Community-initiated and community-driven research initiatives can effectively build the sustainability of international scientific collaborations by training and building capacity of researchers in resource-limited countries. Building such capacity requires appropriate infrastructure, resources, mentorship and leadership training, funding, and research partnerships, accompanied by the highest levels of ethical, legal, and socially appropriate standards for research — a tall order, but one that a group of researchers from the U.S. and Bangladesh have navigated successfully.
In Bangladesh, at least 30 million people are exposed to arsenic in their drinking water. To address this public health crisis, David Christiani, M.D., of Harvard T.H. Chan School of Public Health and Quazi Quamruzzaman, M.D., of the Dhaka Community Hospital Trust (DCHT) in Dhaka, Bangladesh, have been working together since the early 1990s.
Recognizing the enormity of the arsenic crisis, Quamruzzaman realized that his country needed a multidisciplinary approach to tackle the problem. He met Christiani during a visit to the U.S. to bring attention to the arsenic epidemic in Bangladesh. Christiani had previously worked in Taiwan on arsenic and bladder cancer issues, so he had the protocols and an interest to apply them in Bangladesh. A research collaboration developed as they discussed potential projects, which were later funded under the Harvard School of Public Health Superfund program.
At this time, Molly Kile, Sc.D., of Oregon State University was a doctoral student in Christiani’s lab and was using data collected in a Bangladesh biomarker study for her doctoral dissertation. She wanted to see where the data came from and talk to the people who were collecting the information, and luckily Christiani also wanted to provide field experience for his students. In 2003, Kile arrived in Bangladesh, a visit that would turn into a career changing experience for her.
“After my first visit to Bangladesh, I was hooked,” she said. “I saw the terrible effects of chronic arsenic poisoning and wanted to help the people, work with organizations that were taking care of the sick individuals, and provide useful information for establishing safe drinking water regulations. I also became determined to raise awareness about how the arsenic crisis came to be so we would not repeat the same public health catastrophe.” Now Kile has her own research projects in Bangladesh, and this year, she sent her first doctoral student there, initiating a third generation of scientists into this collaboration.
A focus on community is the foundation of all DCHT activities. Consulting local area leaders and engaging the community through discussions was essential for implementing the activities required for this collaboration. “Developing a mutually trusting relationship from the get-go was important for the success of our work,” said Quamruzzaman. “That is why I partnered Kile with DCHT staff who were known to and accepted in the communities where we were working and were good communicators.” Kile said that Quamruzzaman taught her early on about the importance of community participation and buy in. To this day, her work always begins with the concerns of the community, and evolves into the highest quality research possible given the practical constraints of working in rural Bangladesh.
The team uses a train-the-trainer model to train local staff to work on the projects. At the beginning of a project, Kile works with Mostofa who manages extramural research projects at DCHT, and Joya and Suchunda, the quality control officers of DCHT, to make sure they understand all the protocols, before handing over the training of the teams to them and serving as a resource for clarifications. To ensure appropriateness, Kile works closely with the DCHT staff to design study questionnaires and dissemination plans for their findings. “Joya and Suchunda are definitely key to our success,” said Kile. “They have incredible attention to detail and go out in the field with the local clinic workers to ensure all the protocols are being followed.”
“From the outset, we agreed that we could not work in arsenic affected areas without providing clean water options,” said Quamruzzaman. The community-based participatory approach has empowered the community to take ownership of the problem. For example, they now manage their own clean water supplies, people want to understand their health problems and raise healthy children, and communities are using research findings to drive health initiatives in their areas. “These community activities have a ripple effect leading to other development initiatives such as education and workplace training," he added.
“Knowledge transfer, skill, and human resource development through education and working with international organizations are just some of the benefits that DCHT has gained from this partnership,” noted Quamruzzaman. “We have also been able to expand the range of DCHT’s activities both in the field and hospital level.” What have the U.S.-based institutions gained from this partnership? Christiani and Kile agreed that it was the ability to do good science that impacted public health action, exposure of U.S.-based trainees and researchers to global environmental health problems, and their practical training to do high-quality science in resource-limited settings.
Challenges in Global Health Research
All three collaborators noted the challenge of raising financial resources to initiate and continue work. Gaining the trust of the community and ensuring transparency of the research was key for Quamruzzaman. Christiani noted challenges in getting action on the ground and ensuring human subject protection protocols were in place at DCHT. For Kile, language and distance were also barriers. “To overcome these [challenges], we make it a point to meet in person several times a year and utilize many different communication tools to keep the lines of communication open and flowing freely,” Kile said.
Few international research collaborations can claim longevity that spans three generation of researchers. So what is the secret of their success? “Engaging on issues of mutual interest and technology and knowledge transfer are critical to maintain continuity of efforts,” responded Christiani.
For U.S.-based institutions and in-country partners looking to develop long-term sustainable efforts in country, Kile emphasized the need to spend a lot of time learning about and respecting each other’s culture and values. To ensure continuity, she notes the need to work with visionaries who have developed a core group of people who can execute the vision and have planned for succession. According to Christiani, engaging institutions is important, but it is the people — faculty, trainees, and community partners — who should be the drivers. “Mutual respect, commitment, and enthusiasm go a long way,” Kile said. “I would say one of the secrets to our long term success is that we are working with many of the same people we started with, and we have learned the ropes together and have overcome all the obstacles together. This has allowed us to learn from each other and continue to grow. I think it is that simple.”
In the fifteen years since they started, the collaboration has evolved. “First, it was a united front to combat arsenic induced disease. Then, our work expanded to include other metals. Now in the face of rapid changes, and disasters like the deadly structural failure and collapse of Rana Plaza in 2013, we are expanding into occupational health and safety,” noted Christiani.
Observing how the partnership had matured, Kile said, “The focus on community concerns remains unchanged. Doing the best science possible to address those concerns alongside efforts to train and build sustainable infrastructure in DCHT also remain the same. However, the list of different exposures and outcomes, and our mutual respect has only grown over time.”
This effort highlights the importance of building sustainable partnerships in communities where people are the most vulnerable in addressing pressing public health concerns around the globe.