Little R.E., Gladen B.C., Ataniyazova O.A., Monaghan S.C., Tabakova S., Zadorozhnaya T.D., Mendel N.A. Bridges between East and West // Epidemiology, 1997. — Vol.8. — N.1. — P.107-109
Bridges between East and West
The dissolution of the Soviet Union and the subsequent lifting of the «Iron Curtain» provide new opportunities for international studies in an area that was closed to Western scientists for up to 70 years. Our specific interest is the effect of environmental contamination on reproduction. Because of the extensive pollution that exists there,1-3 we have undertaken several collaborative studies in countries in the former Eastern Bloc, including Bulgaria, Karakalpak-stan, and Ukraine. Here, we report the benefits inherent in these studies, the problems that we have encountered in conducting them, and the lessons that we have learned after 5 years of collaboration.
Problems Encountered in Eastern Bloc Research
Reid4 noted the potential benefits and challenges of international research in his classic article. Challenges to be met include, among others, variations in vital statistics reporting, inconsistency of diagnostic standards, and differences in language and national culture that may influence patient reports and disease status definition. These and additional problems specific to research in the former Eastern Bloc can be classified into three major categories: logistics, communication, and differences in scientific training, experience, and frames of reference.
Logistical Problems
Logistical problems are the most obvious of the difficulties but the least serious, although they can cause frustration and delays and sometimes require scientific compromises in the field. For example, many countries in the region are completely lacking in laboratory supplies. Glassware, reagents, and all necessary materials must generally be carried in as personal baggage to ensure safe delivery. It may be virtually impossible to provide hazardous reagents because of the difficulty in transporting them. If equipment is lacking, it must also be taken in by courier, with the reagents or simple supplies necessary for use.
Another obstacle is the lack of convertible currency and a mechanism for international banking. Payrolls generally must be met in cash, in dollars. Only recently has it become possible to wire funds to the major cities in which we work without forced conversion. Cash must still be transported to more remote locations.
Biological samples present yet another complication. There are rules in some countries about taking biological samples and about importing and exporting them, but these rules can change unexpectedly. Even if export is allowed, there may be no dry ice, liquid nitrogen, or other effective means for preserving them.
Communication
Communication between the West and the former Eastern Bloc is difficult because of differences in language, culture, and technology. The most obvious difficulty is scientific conversation when native languages differ. The telephone presents a special problem because misunderstanding increases without nonverbal communication. Most American scientists lack knowledge of Eastern languages and must use English. Thus, difficulties are usually minimized if the chief collaborator in the other country, or a trusted deputy, is totally fluent in English. If the collaborators) have also resided in the other’s country, this experience can help to bridge the cultural gap as well. Otherwise, an interpreter is essential, especially where precise or subtle shades of meaning are being discussed. Slightly different interpretations of words, emphases, or intent make the choice of an interpreter critical. Our best results have been obtained when the interpreter was a scientist and a member of the research team. We cannot recommend non-scientist interpreters.
The use of multiple languages can create additional problems. In Ukraine, the official language is now Ukrainian, after being a secondary language for 70 years, and use of Russian is discouraged. Nevertheless, Russian was the language of science in the past, and many potential interpreters are not at ease in Ukrainian.
The technology for easily communicating between the United States and the former Eastern Bloc has improved substantially in the last 3 years. To facilitate this communication, all principal collaborators and interpreters should have available, if possible, fax machines, e-mail, and a generous budget for telephone calls. E-mail is particularly valuable, but it is not always available in remote locations. Unfortunately, the periodic lack of clear telephone connections can render any form of rapid communication impossible.
Travel should be as frequent as the budget will allow, for electronic media cannot replace personal communication at all levels and stages of the project. During the field stage, especially, it is useful for the Western investigator to spend as much time as possible with the Eastern investigators and their staff to ensure that all are familiar with and comfortable with the conduct of the study, and to provide routine reminders of the project’s priority. Later, during the analysis, it may be beneficial for the Eastern investigators to travel to the West, where analytical resources are often more accessible. Exposure to international journals is generally desired by both sides, although procuring these can be expensive.
Differences in Scientific Training, Experience, and Frames of Reference
These differences are the greatest problems for collaborations between Westerners and Easterners, in our experience. The longer the history of Soviet domination and the farther east the country, the greater the gaps. Quality of education and training is not the reason for these gaps. Rather, the gaps are due to the total isolation of Western science and Eastern science from each other for up to 70 years; divergent methods and values have developed over that time. A simple example is that Soviet definitions of infant mortality, still in use in many areas, result in substantial underestimation of the rate computed by World Health Organization definitions.5 There also are differences in what types of information are available. Environmental data is an example of inaccessible information, for the elaborate labyrinth of reporting mechanisms has made access to it difficult.
One important difference for our work is that there is not a strong tradition of reproductive epidemiology in countries of the former Eastern Bloc. Emphasis often is on ecologic studies of exposure, and many epidemiologists are involved with surveillance at the local level, as is the case in Ukraine. Population-based studies are rare at best. There are few systematic surveys involving data collection, with attendant stress on reliability and validity. The idea of a denominator has not been part of the standard Eastern training. Nor has the necessity for incorporating measures of quality control, determining completeness of ascertainment, and avoiding systematic bias. Eastern investigators, however, are now interested in using Western standards of epidemiologic investigation, and we regard this exchange of ideas as one of the benefits of collaborative studies.
Overcoming Obstacles to Collaboration
The most important factor in successful collaboration is the relation between the principal investigators in both countries, East and West. The higher the degree of trust between them, and the greater the agreement in their scientific vision of their work, the more successful the collaboration will be. Ideally, there would be complementary expertise on the two sides. In our work, for example, the Americans have contributed experience in reproductive epidemiology, statistical methods, and study management, whereas the Europeans and Asians have been experts in reproductive toxicology, pathology, or obstetrics and related disciplines. Nevertheless, disagreements are inevitable, and they can be exacerbated by differences in training, experience, and culture. Then both sides must be willing to compromise with good will and sensitivity.
Another important bridge is the sensitive handling of issues involving subject rights, an area where the experience of the two sides is generally opposite. Informed consent is not a familiar concept. The Eastern investigators believed that requiring signatures would discourage participation in the study. The Department of Health and Human Services Office for Protection of Research Rights has allowed use of an information sheet that does not require patient signature, with safeguards for allowing women to ask questions and to refuse to participate without penalty. (The same exceptions are sometimes granted for epidemiologic investigations in the United States.) Appointment of the Institutional Review Board (IRB) could be an obstacle, since the concept is also unfamiliar in the East. This issue was one of the greatest challenges in communication that we have faced. Fortunately, we have had no problems in implementation. Our experience in an industrial city in Ukraine is fairly typical: an IRB was constituted and met within 24 hours after we arrived.
Western training can help bridge the gap in the two scientific venues; however, we believe it must be long-term to be effective. Short training experiences have a broadening influence on both sides, but they do not change the frame of reference of the investigator.
Another essential step in bridging scientific differences in studies of health is clear definition of terms, as suggested by Reid.4 To facilitate this, we recommend a bilingual codebook developed early in the collaboration so that there is no misunderstanding about definitions or standards. Each term is defined both in English and in the language(s) of the Eastern country. Scientists from both sides work (usually through a scientist-interpreter) to arrive at a common definition of each disease relevant to the study and, if possible, assign an International Classification of Diseases code to it. By that process, we have found reproductive complications that were recognized in one country but not another. The same kind of linguistic give-and-take is used for other documents. Questionnaires are translated and back-translated; for example, the Ukrainian questionnaire used in our study was translated from the English original to Ukrainian and back to English again to ensure that the original meaning was preserved. Although this procedure is a standard practice,6 we stress its importance. When environmental exposures were discussed, diagrams of the chemical structures of the compounds were helpful. Demonstrations of other procedures can help to avoid misunderstanding.
Benefits of Collaborative Research in the Eastern Bloc
Although the studies we have done have required unusual effort, we believe that the scientific contributions they have made or promise to make are substantial. There are reports that health in the former Eastern Bloc is declining at an «alarming» rate,7 but we have had virtually no accessible information on reproductive health except for the World Health Organization (WHO) data reported for each country. The WHO definitions are not always used within the former Eastern Bloc countries,8 however, and political pressure to underreport infant deaths makes past data not credible.9 Our studies have made a good start at a solid description of the state of reproductive health in these countries and suggest areas for future investigation. For example, findings from Bulgaria indicate a relation between oxidative status and pregnancy complications,1011 suggesting several avenues for future work. As another example, we find a high rate of macrosomia in the Aral Sea region12; this finding has been reported in Belarus.13 Further studies exploring the cause are now appropriate.
The difficulties of doing research in former Eastern Bloc countries do not outweigh the benefits, in our experience. We encourage other scientists to explore international collaborations. The greatest benefit to both sides is working in a challenging situation that promises insights that may change the way we think about the problems of reproduction and environmental pollution.
Acknowledgments
We gratefully acknowledge the support of Elena Lukyanova, Chief of the Ukrainian Institute of Pediatrics, Obstetrics and Gynecology, and Co-Director, ELSPAC Children of Ukraine, and her staff in our Ukrainian collaboration. We are also grateful for support and assistance for the Ukrainian ELSPAC study from the Ukrainian Environmental Health Project at the University of Illinois School of Public Health. The International Clearinghouse on the Environment provided support to Oral Ataniyazova during her stay in the United States. We thank Terri Damstra, Freya Kamel, and Donna Baird for their reviews of previous versions of this paper.
Ruth E. Little, Beth C. Gladen
National Institute of Environmental Health Sciences, Box 12233,
Research Triangle Park, NC 27709 (address correspondence to: Ruth E. Little)
Oral A. Ataniyazova
Karakalpaksky Scientific Research Institute for Clinical and Experimental Medicine, Nukus, Karakalpakstan Republic, Uzbekistan
Susan C. Monaghan
Ukrainian Environmental Health Project, School of Public Health, Chicago, IL
Sonia Tabacova
National Centre for Hygiene and Medical Ecology, Sofia, Bulgaria
Tamara D. Zadorozhnaja, Nikola A. Mendel
Ukrainian Institute of Pediatrics,
Obstetrics and Gynecology, Kyiv, Ukraine
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