S3 Ep12: Research into practice: evidence from healthcare

We would never work with the community until we brought them on board that they understood why we were doing something that we were doing, that they also understood the fact that if they participated in research, there was no guarantee that we would have something at the end of it that would necessarily benefit them. But we did design our projects in such a way that even if the hypothesis or the study itself was not a huge success, we left people behind and we trained people from the community that were always assertsward which would remain in the community. Welcome to Vox Dev Talks, my name is Tim Phillips. Well, welcome to a special edition of Vox Dev Talks. In the next few months, we are going to be investigating how research is put into practice. What's done well, what could be done better? What economists might learn from other disciplines? Are we going to be talking to experts in many different areas of policy? Today we are focusing on healthcare, and I'm talking to Dr. Zulfika Booter of the Centre for Global Child Health in Toronto. He also splits his time with the Aga Khan University where he is the founding director of the Institute for Global Health and Development and the Centre of Excellence in Women and Child Health. There's also a huge list of other things that take his time. I won't read out now because it would be the rest of the podcast. But Zulfika, welcome to Vox Dev Talks. My pleasure. Usually on Vox Dev Talks, we interview economists. But your training is as a physician, isn't it? Yeah, I mean I am a pediatrician by training. But sort of somewhere along the way, I saw the light and I worked it to public health. So I do global child health. And for the last several decades, I've been involved in trying to see what can be done at scale for children across the world, particularly in low and middle income countries. And I've been working at the interface of evidence-informed policies and implementation. And your specialisation is in maternal child adolescent health. Has that always interested you even when you're working as a physician? No, my training, actually, Tim, is a neonatologist. I started off by specialising in the care of the very small babies. That's what I did for a good chunk of my time for the first 10-15 years. But that also meant that you couldn't do newborn medicine without looking at the mother. Yes. So I started my clinical training as an obstetrician, then I worked it to newborn medicine, and then headed a very large clinical programme for training and referral care of very small babies in Pakistan, all the way from the mid 80s to, I would say, the late 90s. And around that time, then diverted, as I just mentioned, to much more global issues and issues related to population health. And over time, I have expanded my repertoire of things to beyond the newborn period to the entire childhood. Zero to 20 years of age, which does include school age children, it does include adolescence, and is a much wider spectrum than I'd ever imagined I would be doing. How did you accomplish that shift into public health? Did you have to retrain what inspired you to do it? Unfortunately, at the time when I began my clinical training and practice, the discipline of global health did not exist, either did population health of the kind that I eventually ended up doing. So one had to learn on the job and one had to learn by doing. So a lot of the stuff that I've done and that I now teach many of my students was stuff that I learnt myself the hard way, making mistakes, doing things going out in the field and applying whatever little I knew. So in a nutshell, the kind of studies that I'm involved in are basically what you call large effectiveness evaluations. If they differ from standard research where you do a trial on 100 people here, on 100 people there, much of the studies that I have been engaged in in the last several decades have been around population-based interventions at scale, looking at a whole district-illian population, sometimes more than that, and doing interventions that are very firmly embedded within the public sector programs. So not hiring and firing your own people, but working with people who exist within government programs, particularly community health workers. So as you know, the recipe book for working with community health workers did not exist at that time. So we kind of learnt by doing and by actually failing, succeeding at times, but building an entire community of practice around our shells as to what works, what doesn't work. And some of those lessons have principally moved the needle in global health across many geographies, not just in the region where I work. Tell me about the regions in which you work, where do you specialize? So a lot of my work, by default, because I went back to Pakistan after training in 1985, has been in Pakistan, and fortunately by the time I decided to move out, there was a ready program that I could collaborate with, which was a community health workers program, developed by the government, or Lady Health Workers Program. It is a volunteer of women who work in rural populations. So much of my interest was in rural areas, and this was a program that I developed good link with, and we were able to test sequentially many things that these community health workers could do, and ended up by moving the field forward in appropriate domicileary community-based care. The geographies that I work in are not restricted to Pakistan. I then expanded my work into the more difficult tribal areas, conflict affected areas, the border areas between Pakistan and Afghanistan. I've done a fair amount of work in Afghanistan in central Asia, and because my university has a very significant footprint in East Africa, I can't university spans many several continents. A lot of my work now also includes Africa. So if you take the low and middle income countries at large, or let's say the 98 or 99 countries which have almost all the burden of premature mortality of mothers and children, I've worked in most areas, and I've learnt by working in those areas either. In the field, myself, or by working with secondary analysis and collaborators in trying to understand how things change. Do you think it is important for someone in your position to get out into the field and not do this all behind a desk? 100%, absolutely. You can't do this sitting in an office and in a five-star hotel. Work patterns have changed, most go with. A lot of us now work remotely, but I spend a lot of my time in the field and with my staff. Increasingly, I don't have to go to the field every day, but there were periods of time when I was doing some of my work where this would be part of my routine. So yes, you learn by doing. But in rural areas, you also have to pace yourself and develop a program where you can work with other people because short of transplanting yourself into a rural outpost and staying there for years, the only way of doing that is to build a team. So I've built teams and I'm so very proud of them. The teams of people that I work with in Pakistan, I work with in other geographies, I work with here in Toronto. And they are the best and the brightest and the most motivated young people who want to change the world to a better place. In talking to other people who've worked in the field in community health, you realize that it is extremely hard work and can be very frustrating. You've been doing this for quite a while now. Would you say to them, stick with it because you can achieve things? Well, there are several ways of working with communities. Some are things that we would never advise people to do, even though it may be easier at times seen easier. And people do that without necessarily building that rapport, that understanding, that relationship with communities that is so important for work, a lot of people think that that's maybe not necessary. You have a project you go in, flashing your dollars and your resources, and principally implement your project. And in many poor communities, people will participate in research because sometimes it's the only way for them to get some degree of benefit. It is unfortunate, but is a reality. Our approach had been the total opposite from the very beginning. We would never work with a community until we brought them on board, that they understood why we were doing something that we were doing, that they also understood the fact that if they participated in research, there was no guarantee that we would have something at the end of it that would necessarily benefit them, but we did design our projects in such a way that even if the hypothesis or the study itself was not a huge success, we left people behind and we trained people from the community that were always assets which would remain in the community. In one of my rural districts in Pakistan where I've been working for the last, you know, I would say 25 years or so, that is the fundamental reason why we are held in both high regard and also where people take us pretty seriously when we come with the proposal because they know that we have the staying power and also that we will work with them and not throw a solution at them with they have not been part of. Do you have particular examples of where research has influenced policy that has been able to make a difference as away in which things should be done? My very first project that actually changed global policies significantly was based on the principle of trying to save newborn lives in home settings where babies would not necessarily either be born in hospitals or be taken to hospitals and if they had problems they would need to be seen pretty quickly. And to address that we put a project in place I'm going back to 1998-1999 where we work with a community to first understand barriers and what needed to change and then worked with a lady at the workers program to see if we could put in a simple enough not very not very high-powered fancy difficult but a simple enough process of community mobilization and working with women in the communities and all we did was to encourage male volunteers to give them the space the support the elbow room to have them work with women in their own communities to empower them to give them the information and to also encourage them to implement evidence informed good strategies at home and partake of whatever was available in the health system. The results were phenomenal. This took me five years at that time and enormous amount of resources but the results were unbelievable we were able to demonstrate a reduction in deaths by about 20% which you know at a population level of about a million is not insignificant. We were also able to show that many of those impacts were sustained even after we left. So we showed that during the course of the cluster randomized trial that we did people began to go to hospitals the care seeking patterns changed and then four years after we had gone we went back to see if they had regressed to where they were before no they hadn't when people start seeing the benefit and something they don't go back and regressed to a less than optimal health status. So that project was the first with public sector programs changed global policy in terms of community health workers and also influenced the development of a very large program in India. At that time in Pakistan lady health workers were only about 60 or 70 000 India was able to put on a program with a million health workers based on the same principles working with communities families and was able to expand that also. So yeah I mean these projects have a way of snowballing sometimes they can have impacts in direction that you least expected. Do you still have examples of projects now that have that level of impact? Yeah I'm doing one right now which I'm very confident just going by the response that we have to that from communities that will make a lot of difference in that geography and that's a project on trying to build community resilience and adaptation against climate change particularly extreme heat many people are not aware of the impact of extreme heat and conditions on health particularly the health of women and young infants because this has just never been conceived as an issue before and it's also that it's also become a problem in the last decade or so. I mean the average number of days that you have people exposed to temperature particularly pregnant women women work in the fields to temperatures about 40 45 degrees centigrade I mean that's not trivial yet the community adaptation around some of those has not been perfect and that's why there's a high burden of morbidity and ill effects of this so my team is now working on developing a package in consultation with the community which is low cost interventions awareness and also adaptation which is feasible and possible within the social cultural setup if we succeed in a year or two in demonstrating that that did impact health and other outcomes improved maternal health in particular reduced some of the gender disparities that we see around climate change and its impact I think that will push the needle on so many things that will happen even before COP27 or COP28 or beyond are able to get their act together we can't in issues like this which are basically existential wait forever for the global agencies to get their act together so this is community empowerment and this is learning from the traditional wisdom of communities at times that has been discarded over the years as there been examples of any research which you have seen and well it is surprised it's challenged you but you have been able to put it into practice and you've seen those results we a long time ago also did one of the first trials of looking at how we could improve the care of the newborn baby by cleaning the court with an antiseptic solution when they were delivered at home in dirty conditions and whether or not that would make an impact and it's surprised me to see how much impact it had on reducing morbidity and mortality not just because people did that antiseptic application with chlorhexidine but also because they stop doing other things which were harmful now that changed global policy and this is now something that W show has also picked up as something that they do in circumstances where deliveries take place in less than hygienic circumstances but you know you haven't asked me this but I will tell you that some of the best projects that I've been involved in where I think there has been global learning are those that failed because they also told us the limits of interventions you know it's not that everything that you put in place succeeds so these community health workers that I've been working with for and as I said you know the last 30 plus years sometimes you also have the misperception that they can do everything and that you know you could put additional burden on them of new interventions of new targets and new things to do without something giving away and we have learned over time that there are things that will work in the hands of community outreach workers and health workers and there are things that they are equipped or perhaps in place to implement and that's where you need to perhaps go to other interventions in the health system at facility level to make a difference so the balance between what you do at population level in communities and what you do in health systems is something that you learn over time and I've learned more from my negative studies than I have from maybe the few positive ones that I've been involved in a large part of our audience development economists is there anything that you feel that you've learned from interacting with economists yeah I mean I learn all the time by interacting with economists I've learned also how important it is to keep the host principle of cost effectiveness in mind and also the principles of scale some of the the best social experiments that I've seen and I've seen the impact of have been the kind of things that development economists have come up with recently I evaluated some of the results and outcomes from a very large health insurance scheme that was implemented in the North of Pakistan called Seth Sohlukar it's a card that gives a family a certain amount of money and like many other academics I was very skeptical in terms of you know how much can they achieve what would be the proportion of malfeasance when money changes hand at that scale and I was also very interested to see if it would reach those who had relative easier access whether it would increase disparities are than reduced disparities very pleasantly surprised as to how much impact it had on reducing inequities how much impact it had on increasing access of care access to care for those who would never imagine coming to a hospital for tertiary care and surgery in the past I mean obviously I was able to identify areas where they could do better for example moving into much more preventive more than primary care more as opposed to tertia but you know that's a development step that comes step by step so what I'm saying is that I think the best opportunities for making impact are when geeks like me who are from the health research perspective and more implementation research join hands we develop and economists and we did exactly that when I was part of the disease controlled priorities project the last one there is new one coming out DCP3 I mean we learned a tremendous amount by interacting with development economists people who were able to translate a lot of the work that we were involved in into dollar and dime figures to say if you want to make that investment or that choice this is what it will cost and if you don't then this is the alternative those partnerships Tim should increase and sadly they're not the common way of doing things so for the field of public health research has expanded enormously since you were one of the pioneers of it is there still a category of things that we just don't know enough about yet the two areas that I will point out to you one that I initiated six seven years ago because there was no work in that space so I set up a consortium of universities some of the best academic centers in in northern hemisphere in partnership with universities from the south it's called branch consortium bridging research for action for improving maternal and child health in conflict and humanitarian settings so we researched first of all what burden of global mortality morbidity for women and children existed in geographies where conflict was not only acute but you had these never-ending wars and long-standing conflict circumstances such as you have in the horn of Africa sitting in my own backyard you know I come from the north of Pakistan I was a young graduate when I worked in my first refugee camp because of the Afghan war look at where we are now I'm now an old man, so these things have. a habit of perpetuation. So nobody works on those areas. The only people who work on those areas are implementation bodies like NGOs, very well-meaning NGOs and heroes in my opinion, but they're generally not led by science. So our objective in that consortium was to build the scientific basis for doing better, to make the case for more research in those circumstances so that you make the right choices. And I think a series of papers that we produced in the launch said push the needle a bit further. And then unbeknown to us, we were hit by COVID and the world came to a standstill. A lot of our implementation work beyond that particular project did not take place because there was just no way of doing things during the two or three years of the world that come to a standstill. But the Lord works in mysterious ways and in some ways it was good that I didn't rush and do anything because now what I am engaged in pushing the branch consortium for is actually to work on complex crises because even conflict itself is a very narrow definition of what those poor people go through. I mean, these complex crisis, whether it is COVID or post-COVID pandemics, whether it is conflict, whether it is cost of living or its climate change, these are things which are intimately intertwined. In my own country where I work, Pakistan, you go to rural populations of synth and you can't talk to them about one thing. They are dealing with many things simultaneously. They are dealing with existential floods and climate change. They are dealing with food insecurity. They are dealing with the fact that they can't afford to put one square meal a day on the table. And they are dealing with the fact that they also have health crises that are becoming more common in the wake of such outbreaks. And also importantly, they are dealing with issues of quality of care in health facilities. You need to develop a strategy for working which is more around complex preparedness. So while I just told you that I'm doing this climate change package for heat adaptation, I know that that package eventually will have to also include issues of affordability, cost effectiveness will also include things that have to be done for that community to become more resilient around their own food security. And also have to include issues that have to do with better management of disease outbreaks and preparedness. These things are intertwined and the more intertwined they are, the simplistic solutions that only work through one sector do not work. So we need multi-sectoral interventions and approaches. This morning in a discussion of the SDSN led by Jeff Sachs, this was precisely my point. Looking at this purely from the financial lens is inappropriate. Looking at this purely from a health lens or a climate change lens is also missing the point. You need to increasingly have communities, district governments, provincial governments and federal governments. Look at this from the lens of trying to do things together in a much more complex preparedness mode. That's where I'm heading. And for the specialists involved in this, is it important that the teams that are designing any interventions are also interdisciplinary? Completely, absolutely. I think that's where the opportunity and the challenges, the challenges very few of them are. You ask people around how many people have anthropologists, how many people have qualitative scientists as part of their team, is there a small fraction? How many have developmental economists? Health economists? Very few. I know that in my own program, you know, we would have done with the health economists like yesterday. And also increasingly bringing in the community voices through women, through civic society, participants, participatory planning and development of these projects, I think is not the exception. It should be the norm. And it's increasingly something that we recognize as we get into more difficult areas. So, is there something that the development economists can learn from people in your discipline with your background? I think the more we see developmental economists, and with due respect to most, spending time in the field with grunts like us who spend their days and time working with communities, the better off many of these things would be. I mean, I see many developmental economists, many of my friends, you know, spending less time in community settings, breaking bread with, sleeping, living and experiencing some of the things that they are so passionate about and want to change. We would need greater collaboration and development of projects where this becomes the way of designing things. Are you encouraged that the movement is in that direction? In some places, yes. In other places, you know, I think one of the big and I'm saying this with great sincerity. One of the unfortunate things that has happened with COVID and the life and way of work after COVID is that more and more people are working remotely. Yeah. I think while just has efficiencies, it also means that you lose that human factor in terms of co-designing things by sitting together. So I think increasingly, I would encourage people to in partnerships with low and middle income country researchers, people like myself, is to develop those partnerships on the basis of a mutual common understanding of what we are trying to change. I remember, gosh, you know, this is such a long time ago. Jim Grant paid a visit to Pakistan, which was I think mid 80s. And it was it that relatively safe, people wanted him to go to a village close to Karachi. But I remember that he insisted that he wanted to go further out into the interior. Why? Because he wanted to go on an unscripted trip. He wanted to see for himself. He wanted to feel with his own hands and see what was happening with things that he was so passionate about oral rehydration, immunizations, nutritional monitoring. So that's the kind of spirit that I think we need with people in global development is to be able to see for yourself firsthand and not only see and diagnose, but also be part of the solution by seeing and monitoring and assessing the impact of many of the decisions that we take sometimes in the near-conditioned boardrooms around what a design of an intervention might be. Zulfi, it's clear that you still have that spirit. Congratulations on everything you've been able to achieve. Thank you very much for talking about it to me today. Thank you. Thank you very much. And thank you for having me. I also believe that I have to congratulate you because you are the recipient of the 2023 Henry Freeson International Prize in Health Research. Oh thank you. It's going to make your CV even longer. This has been VoxDev Talk the best way to make sure you don't miss an episode is to subscribe wherever you get your podcasts. You will find us there. And if you do miss an episode, all the past episodes, as always, are at VoxDev.org where you will also find articles on the papers we feature.