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Understanding and Preventing Micronutrient Deficiencies: Going Behind the Scenes with Dr. Keith P. West

The interview was conducted on July 20th, 2017, by:
Iffat Ara Sharmeen (senior), Farah Husyn (senior), and Samara Tawziat Choudhury (junior)
School of Life Sciences
Independent University, Bangladesh

Published on September 23rd, 2017 

Dr. Keith P. West is a George G. Graham Professor of Infant and Child Nutrition, and Director of the Program and Center for Human Nutrition within the Department of International Health at the Johns Hopkins Bloomberg School of Public Health. He is a leading international figure in public health research and has been working in rural Bangladesh for decades. On July 20th, Dr. West spoke at a seminar organized by our department (SLS) and the International Center for Biotechnology and Health (ICBH) at IUB. In his talk, entitled “Preventing Micronutrient Deficiencies: Mechanisms of Impact on Health and Survival”, Dr. West described much of his research in Bangladesh, Nepal, and other countries.

Dr. Keith P. West during his seminar talk

HERE BE DRAGONS conducted a brief interview with Dr. Keith West during his visit. After an energetic and engaging seminar, Dr. West rather amazingly agreed to answer our questions about his research and career. His answers contain valuable pieces of wisdom for students and early career scientists, and great insight on the dynamics and logistics of running large-scale population studies in places like rural Bangladesh. The following is the transcript of our interview:

Farah: Most of your studies are conducted in very rural regions. How did you convince people to look past cultural inhibitions or perhaps, mistrust? There are a lot of taboos regarding social contact and sharing information, so how do you overcome those?

Dr. West: That’s a good question, and it relates to how one sets up and maintains a research project, because culture and community perceptions exist everywhere. It takes 1 to 2 years to set up set up a research site.  It is important to meet local officials, the government agencies and local groups like women’s groups, teachers and religious leaders. You meet with a whole reach of leaders who will take interest in what you are doing to explain what the research goals are and what the processes are. Now, in JiVita (in Gaibandha), we have carried out several studies. So far, there’s been over 100,000 pregnant women studied, and over 70,000 babies have been in various JiVitA projects. There’s lots of reasons to do each study but every time we do a study we go to the community and explain what the issue is, who we are looking for to enroll, why, what the procedures will be for participation, and then we get permission to go into the community to do recruitment. It’s an enormous privilege to do the research and so important to inform potential participants and earn the community’s trust. At the time of recruitment if it’s pregnant women for example, there will be individual informed consent and at that point we explain in more detail what the purposes are, what the potential risks are in participation and what their chances are of getting one treatment or another. So, for example, there may be a 50% chance of getting a vitamin or mineral supplement versus a placebo, if it’s a double-blinded trial. To make an informed decision about whether to voluntarily participate, mothers need to have that information. So, it’s lots of different things to explain to the community. 

Another thing that we try to do is to keep the the local press informed about a project. It’s another way to get information into the community and lets the local media understand the goals and activities of a project before it begins. This also helps to establish trust, openness and better understanding so that if rumors, or even actual problems, arise - because things can always go wrong from time to time with 750 staff and tens of thousands of people in a study - everyone can address the problem from a common understanding and sort it out.  It’s important to have processes in place to try and find out what is the problem and deal with it in as fair a way as possible. We have research staff who go into the community to try to resolve issues. By doing that mutual trust develops between the research project and the community.

Its also important that a research project be a good citizen.  We rarely have a budget for extra activities, but when there’s a disaster, we try our best to support the district government, providing emergency care or other supplies when possible, such as when there was a tornado or when floods have occured, or providing blankets and clothes during a cold winter. It’s not part of the research, but it’s part of being a good citizen in the community in which we work. Of course, by hiring several hundred staff it helps the local economy as well because our staff live in the greater Gaibandha area. This also helps to build good rapport with the community.  Good relationships are earned, it doesn’t happen right away, but rather evolves over time.

Sharmeen: While working on a project in Bangladesh, what was the most frustrating experience that you have ever had, or the best one?

Dr. West: The most frustrating experience is one that I think is common to all researchers:  Staying on schedule amidst many challenges and getting a study done on an always limited budget.  Both are related!  Even good planning may not always work because things happen that are out of one’s control. There can be delays in obtaining ethical approvals of a protocol that, for JiVitA, must happen in Bangladesh and at Johns Hopkins University; supply shipments can be delayed; security threats as we have seen in recent years, can delay starting or interrupt a study. This creates tension because staff salaries, office expenses, and many operations costs have to be paid every month. So if we delay things for three or four months, it causes severe financial strain, because you want to keep paying people and your bills but also need to get the work done.

The best experiences come from watching a research organization function under rural conditions, and seeing that everybody knows their job, everybody is doing their job and the system is working. In JiVitA, we have 750 truly professional staff, at every level; they are organized into sectors and teams and are coordinated by capable supervisors. More than 85% of our staff are women who are local residents!  So, in a study, you see things happen – for example, over 1 lakh households are visited by staff every month, women get identified as pregnant, they are informed and consent if they wish to participate, and begin to be supplemented for a time period, on protocol.  Data are being collected by standardized interviewing methods, being transmitted to a data management center in Gaibandha, where data are being compiled, checked for errors and gradually a reliable database is built that gives a picture about the community, about nutrition, health, pregnancies, births and all events going on.  The data can be analyzed, understood, interpreted and reported with confidence that it is based on the best data possible.  That’s very satisfying.

Samara: Most of your research has been on Vitamin A. What specifically triggered your interest in vitamin A compared to other micronutrients?

Dr. West: It was the first one I came across (laughs). You know there are chance events in your career. You choose to take advantage of those chance opportunities, or let them go and wait, maybe, for another one to come along. I was here in Bangladesh with Concern (an international charity organization) for a couple of years before I did my Master’s. I started my doctoral degree and I was looking for a thesis. So, I got interested in Vitamin A because my research advisor Alfred Sommer was working on Vitamin A. I met Alfred Sommer when he was a young ophthalmologist, who later became Dean of our School.  He had just come back from Indonesia with ideas about trials and new studies. The opportunity presented itself, and I took it. It led me to pursue the prevention of vitamin and mineral deficiencies for the rest of my life!  

When students come to me for career advice, I always tell them to pick a ‘quadrant’, a general direction out of the 360 possible degrees in which they think they can go in their lives, out of all the things they want to do. Instead of choosing only one way, take any opportunity that takes you in that general direction, the quadrant, that you picked. Your choice will lead to new opportunities that you can not easily imagine.  After working with Concern in Bangladesh for a few years, I knew I wanted to work on nutrition in South Asia.  Al Sommer was starting on a new project and asked me to join, in nutrition, in Indonesia  - close enough, in my ‘quadrant’! - and, so, I took my chance, which eventually led to new chances to work back in Bangladesh.  It opened up my life.

Sharmeen: Do you have any word of advice for students with a budding interest in public health?

Dr. West: Come to Gaibandha!

For more information on the JiVitA project, visit here.

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