Building a Career in Maternal Health Research
Insights from Dr. Zulfiqar Bhutta & Dr. Isabelle Malhamé
This interview has been edited for length and clarity by Miriam Gladstone
Dr. Zulfiqar Bhutta, a co-director and senior scientist at the Centre for Global Child Health at the Hospital for Sick Children and world expert in global maternal and child health, has devoted his life to ensuring that evidence-based medicine did not leave disadvantaged women and children behind. Recently awarded the 2023 Johns Dirks Canada Gairdner Global Health Award, Dr. Bhutta has mentored countless students and young professionals who are passionate about improving health worldwide. He recently selected Dr. Isabelle Malhamé, assistant professor of medicine in the division of General Internal Medicine and an attending physician at the McGill University Health Centre, as the recipient of the Gairdner Foundation Early Career Investigator Award for her work reducing severe maternal morbidity in Canada. Here, Dr. Malhamé and Dr. Zulfiqar engage in a conversation to provide guidance for other young professionals wishing to build a career in global health research - including learning from one’s mistakes and the importance of community engagement in research.
IM: What piece of advice would you like to give early career scientists with an interest in global maternal morbidity and mortality?
ZB: The first thing I would say is be brave – if anybody says something is impossible, that it cannot be done, all they’re encouraging you to do is to find a way around big problems. That’s exactly how I found myself in the mid 80s and early 90s confronting the big global challenges that I was seeing around my own working environment in my own country of birth, Pakistan. There was absolutely nothing on the table at that time that would lead to health care reaching populations living in adversity in slums in big cities. Over time, the magic bullet that came out and lifted a lot of people out of that despair were strategies that were community based. I remember talking to people at that time who said, “Forget it, go back to your intensive care unit because you can’t save newborns in rural settings. Or if you can, it’ll be the heroic efforts of an NGO doing and then you’ll be working all your life to sustain it.” But in the words of Nelson Mandela, “it’s only impossible until it’s done”. The first thing is, principally, don’t let people dissuade you. If your vision is to tackle these big complex problems, then you will find your way.
The second is to not rush. Everything takes time. I find a lot of early career and young researchers want to achieve things in the shortest possible time: “How can I go from an assistant professorship to an associate professorship in two years? How can I become a department chair before I’m thirty?” One can, but I think in my own opinion and experience, success in practical terms in global health comes to people who are patient and committed. That advice also brings the understanding that every failure is learning. There’s lots of people who get very dissuaded by something not working, or not working according to plan. At our Gairdner awards this year, the MRNA vaccine story is a story of failures. It would be very easy to imagine how Dr. Kariko could have given up completely. But she was determined to prove to people and to prove to herself that what she had was worthwhile. It was key in many ways that she found collaborators who were willing to help her. So, the second thing that I would say to trainees and early career researchers is take your time. Linked to that, is learning with everything, and learning from failure.
The third is a very personal recommendation that I give to most of my own students - don’t run after success or fame or glory. The more you do it, the more it runs away from you, and you will only cloud your own mission, vision, and work. We developed the discipline of global maternal child health at a time when there was no guidebook, there was no global program and most public health programs did not have a focus on the MDGs. Sometimes, it is important to develop your own niche and your own discipline. Many times, I hear students say “I will do an evaluation of what opportunities are out there and then cater my career accordingly.” I ask myself at times, it probably ought to be what problems out there can I solve rather than what opportunities are there out there.
IM: This is extremely insightful and helpful to hear. In trying to develop and establish a Canadian Obstetrics Survey System, to better understand serious complications occurring during pregnancy and postpartum, we’re trying to build partnerships with smaller centers and rural communities that are not usually captured within established research networks. Can you give us a little bit of insight about how you’ve been able to build connections and engage with varied communities, do work with them, and co-design projects with them on such a large scale?
ZB: First of all, I think when working with communities, a lot of people confuse illiteracy with idiocy. Many poor populations that are illiterate may not have formal education – they don’t have a PhD, they haven’t done Masters’, but they have far greater wisdom in dealing with real life problems and issues than many people give them credit for. One of the things that I’ve learned over the years in working with communities that are very impoverished is that if you scratch the surface, you can see the richness in those communities - in their social capital, in their knowledge, and in their way of thinking - which is at times more ecologically friendly and grounded than what I find elsewhere.
Why am I telling you this? Canada is a melting pot of every ethnic group, every cultural group, and every religious group. This is one of the few countries in the world where you see Global Health in front of your eyes. Here in Toronto, if I want to see Global Health all I have to do is take public transit to my office and I see Global Health in front of my eyes. Because I came from a relatively poor part of Pakistan and because I really wanted to learn how communities survive and build resilience, I have always listened to them. If you go and ask many of the populations where I work extensively with people, that’s the one thing that they appreciated and valued in our interactions. I learnt from them how they deal with complex problems in their own way and with limited resources. What do they recognize and consider sustainable? How do they view parachute research where people come in with fancy solutions and have no eye on sustainability? You build rapport by a process of interacting and learning with people and co-developing approaches. You’ll have a much greater chance of not only being sustainable but also being implemented and taken up by government. Governments are, at the end of the day, all political animals and they will have much greater chance of developing something and sustaining it if they see the value in civil society. For a lot of the things that we do in Global Health, particularly around women’s health, you’ve got to get community on your side and talk to people to understand who they are and what they want. When you do, you have a much better chance of working with them.
IM: Once you have meaningful research findings and communities on board and you think that you have an intervention that could really change the face of women or children’s health, how do you get the governments on board with you? Have you developed a strategy to mobilize governments and effect policy change?
ZB: You must be very careful because every researcher thinks that he or she has the panacea for the world’s problem. I find that there’s a tendency to take a single trial’s findings and try to scale it across the world. The benefit of co-developing an intervention with the public sector and with the government is that because of the very nature of the engagement process, they already have committed to work with you. The second thing that I would say is that you must be sure that whatever message you’re taking forward is sound and evidence informed. The pathway to knowledge is not just efficacy trials, but it’s trials at scale and effectiveness in real life. You need to actually do the implementation research to see how [these interventions] can be scaled up. In COVID, while you had a lot of evidence from trials, the real evidence of a vaccine effectiveness was real life implementation. We have seen while so many vaccines are highly effective in long-term studies and in real life, their effectiveness is less than 50%. You must be careful in terms of extrapolating – look at the context and make sure that your study findings are replicable. Other people reproducing your results is one of the best accolades that any researcher can get.
IM: That’s very helpful. My next questions relates to how you spoke about taking our time in research. How do you decide when a question is sufficiently ready to be addressed by a clinical trial? When do you decide that it is the right time to “go in” with a clinical trial? For example, in questions related to the management of severe hypertension and preeclampsia.
ZB: I’ve spent almost 10 years of my life trying to answer that question and I can tell you exactly where we got to. The [Community-Level Interventions for Pre-eclampsia (CLIP)] trial was a trial where the same kind of thinking prevailed. Could we develop a strategy for recognition of pre-eclampsia and eclampsia risk at scale. It was done in a very careful manner, but based on the theory of trying to take something that had worked in British Columbia and many other places. We thought that we conducted risk assessment very well, we persuaded the government to let us train and work with the community health workers, and we implemented that at scale and spent 5 years and millions of dollars doing this. The trial disappointed in its primary outcomes - no effect on mortality, only some effect on community mobilization. What mistake was made? The one thing that you must recognize with severe hypertension management is that you need to work concurrently with various tiers of the healthcare system. The trial was principally designed to look at community-based approaches at that level in the main, it did not sufficiently consider that you have to have preparedness at the level of the health facilities. There was very little point in training community health workers in recognizing and managing preeclampsia - even to the point of giving Magnesium Sulfate in community settings and referring them to facilities - if the facilities were not ready. If facilities didn’t know what a risk score was, or if they did not act on things in the same level of urgency. In hindsight, that trial should not have looked at one element it should have looked at the whole package.
What do you get if you both strengthen facilities in terms of managing pre-eclampsia and you have community health workers implement a strategy for early recognition and referral. I have a feeling had that been done we would have probably seen a difference between outcomes with those combined strategies and with routine management. I wish instead of spreading that money across three or four countries, we had principally just done it in one and done it at scale and in a manner that would have allowed us to look at outcomes, not only at primary care but facility level.
Does that mean that the community strategies don’t work? No. I think the trial was very promising, but it showed that you cannot just rely upon training community health workers for something as serious and severe as maternal hypertension. We must combine primary care recognition risk factor assessment and referrals with solid management in facilities.
IM: Any concluding remarks for us Dr. Bhutta?
Overall, my advice would be: don’t be intimidated by anyone. Don’t let people tell you it can’t be done. There is no big problem in the world that human ingenuity, perseverance, and innovation cannot solve.
Thank you Dr. Bhutta and Dr. Malhamé for your time and insight.
Dr. Zulfiqar Bhutta is a co-director and senior scientist at the Centre for Global Child Health at the Hospital for Sick Children and world expert in global maternal and child health. His research aims to reduce maternal and child health and nutrition amongst marginalized and rural populations.
Dr. Isabelle Malhamé is a Junior Scientist at the MUHC research institute and an attending physician in the Department of Medicine in the McGill University Faculty of Medicine and Health Sciences. Her research focuses on improving maternal health by reducing pregnancy-related severe morbidity, including from cardiovascular and thromboembolic complications.