A Conversation with Anita Zaidi — A Discussion of Global Child Health, Empowering Women and Creating Change for the Better

Anita Zaidi, MD SM, an internationally recognized pediatrician and director of the enteric and diarrheal diseases program at the Bill & Melinda Gates Foundation, discusses the issues impacting maternal and child health and her work in her home country of Pakistan, which has the third highest infant mortality rates in the world.

Let us start with discussing what led to the Anita Zaidi we see today. How did your parents impact you and your interests growing up?

My father was always motivated by passion. Although he was an anesthesiologist his true calling was actually sports medicine. In pursuing this interest, he became the Pakistan Hockey team national physician and actually used to accompany the team on many of their tours! But what I really remember is that work was not about money. There would often be many amateur hockey athletes coming to his clinic and there was never any question of their paying any fees. And he just lived his entire life like that. I think I internalized that, the concept that you can just be driven by passion and really enjoy your life and every moment of it. So that work is not work, it’s just something you love doing. That, in a nutshell, is my relationship with work is: that it doesn’t feel like work. I truly love what I do so much.

What about your childhood defined your career?

It has only been quite recently that I have recognized a pattern to the behavior which has driven many of my personal and professional decisions — which is when choices have presented themselves I have wanted to pursue the more challenging, harder path, in fact I would say I have thrived while navigating uncharted more challenging routes. A good example would be actually from back when I was in high school. As a teenager I remember feeling bored in the school system in Pakistan. I did very well in it but felt it was not challenging enough. I remember in 6th or 7th grade, the high school I was in, St. Joseph’s, had sent a parent information brochure discussing the option of taking exams with a British exam board, the O’levels. My parents didn’t even know what it was and at that time they said, “No she will study in the Matric system”, which was the local Pakistani examination board, “ We have no idea what this UK based system is”. Funnily enough as it happened, after taking my matric exams I went to the UK on a summer trip and came across some of my cousin’s school text books. As I read them, I realized how totally different they were and how much more challenging the curriculum was. So I called my parents back in Karachi and told them I was staying back in England so that I could finish my high school in the UK system. Similarly, the summer after I completed my 10th grade exams, before I left for the UK I decided I wanted to learn more microbiology and thought of working in a local clinical microbiology lab. So as a 15 year old, I ended up working in the summer in a clinical commercial laboratory in Karachi!

In an interview with the Lancet in 2013, you described how as a fresh medical graduate your awareness of life for Pakistan’s impoverished communities grew when you spent time working in remote northern Pakistan. What made you take that decision? More so how did this experience mold you differently?

As a medical student I really enjoyed our Community Health Sciences coursework and the exposure we had to working in katchi abadis (urban squatter settlements) as part of the Aga Khan University (AKU) curriculum. At that time we had an instructor by the name of Zeba Mohammad (now Rasmussen) who had trained in the US and was teaching clinical medicine at AKU. I had worked as a student with Zeba on describing antimicrobial resistance in typhoid. Around the time I graduated from medical college in 1988 Zeba was setting up a diarrheal disease control program in Gilgit, Northern Areas, Pakistan. This was funded by the Applied Diarrheal Disease Research program of the USAID, and she was looking for a research assistant. The project would involve setting up a community based surveillance program for diarrheal disease, working with Community Health Workers and to then do a morbidity assessment in the Northern Areas of Pakistan to understand what kind of health care infrastructure the Aga Khan Health Services (AKHS) would need to implement to improve population health status there. I joined her as a research assistant on this project and as a young doctor, I could see that when you trained people it really changed how they interacted with the community — all the work we did was extremely meaningful. In fact, the research program ended up not resulting in a publication — but the morbidity surveillance we did was published as a full report for the AKHS which they took very seriously as they knew our findings were important for their planning. For me, this was a wonderful learning experience and I gained so much knowledge about the Pakistan health system, community health workers, the importance of midwives, how to implement a program etc.

Who have been your sources of inspiration through your career and who has mentored you?

I have been very lucky in that I have always had great mentors so Zeba was an early one. Then when I was an AKU medical student, there was a visiting infectious diseases faculty member, Claire Panosian* from the University of California, Los Angeles (UCLA). She invited me to come spend time in a clinical elective with her at UCLA in HIV medicine. The whole experience and time with Claire was so inspirational. I fell in love with infectious diseases as a career choice. Then at Duke, Sam Katz* and next in Microbiology, Barth Reller*. At Children’s Hospital Boston, Don Goldmann* was my mentor. From each of these, I learnt different things: from Sam just observing what a generous and visionary personality he is — and how he would take bets on people. From Barth I learnt academic rigor and fastidiousness in writing. Lastly, from Don Goldmann at Boston Children’s, how to be sharp and incisive in my analyses along with how to think strategically. And how to raise your game to meet challenges.

You have been in several key leadership positions throughout your career — what characteristics of yours do you think led to your assuming those positions?

For me it has always been about the work that needs to be done and then leading from that changing the way we think about a problem. Even my earlier work about how people use the clinical microbiology lab for pediatric problems was about how to change clinical practice. I have never, however, cared about positional power — I think you can change a lot of minds and do a lot of things in different ways without having formal authority. The main way, I think, how you influence others is by your informal interactions such as how you present yourself, how you greet other people, your enthusiasm, your behavior with collaborators, being open to others ideas — all of these go towards building trust which is great for getting work done. So formal authority for me has never been a goal, it has just sort of happened on the side.

Have you ever doubted the career choices you have had to make?

In fellowship, I had to decide whether to pursue work in a basic science lab or pursue a more clinical route — since I already had a bench work background in clinical microbiology, I thought the Masters in Tropical Medicine (SM) would help me more along with developing my decision analysis skills than bench work in a lab. At times I thought I was making the wrong decision especially at Harvard where most of my colleagues at Boston Children’s were pursuing intense basic science lab work in their fellowships. I remember those as a few uncomfortable years when I was not entirely sure whether I was thinking correctly or not. But it ended up that the SM was very useful for the work that I subsequently did in Pakistan.

Not many doctors who leave Pakistan to train abroad return — what do you think was different about your approach?

The people I trained with, both in medical college, and clinical residency and fellowship training in the US, have all done amazing work just in different ways — what was different about me when I look back, was that I knew I was going to go back to Pakistan. So there was always what do I need to know which would be helpful when I return to Pakistan. I was very lucky and glad in that I had AKU to go back to. Not everyone has that opportunity or an institution of such standing in a developing country that they can work in. But it is important to realize that it is not easy to settle in when you initially return. Going back with an open attitude of, ‘I do not know much and want to learn’ is what makes you successful. There are multiple ways of getting about to any solution, or what is referred to as, ‘jogaardh’, essentially the Indian word for improvisation. I do not believe in confrontations and always look to see if I cannot do this task in such a way then is there any other way I can get to the same outcome? Even at AKU I realized it would be very difficult to pursue infectious diseases in the clinical setting because there were some fantastic clinicians who were very competitive and understandably did not want a new young person coming in saying, ‘Hey I am the cool new infectious diseases doctor!’; so I sat and thought about whether there were other ways in which I can apply my knowledge? So, with my infectious diseases training along with my interest in public health and child survival it became clear very quickly that there was an immense amount of work I could do in an area that no one else really cared about at that time and truly was therefore open for making an impact in. The first project I worked on when I returned to Pakistan was the Young Infant Clinical Signs study and I was very nervous that I would not know how to do it as I had never trained people in these urban community settings for such a large project. Dr. Zulfiqar Bhutta, senior researcher in the Department of Pediatrics at that time had a very experienced Research Assistant Shumaila, who had been working with him for several years and all he told me was, ‘She will help you’. And truly she was just amazing! She taught me so much about the work the Department of Pediatrics was doing in the community and helped provide the bridge that I needed as a newly starting out junior faculty member.

How did you go about the process of engaging the government to get the Hib Vaccine introduced? Are you expecting similar success with rotavirus vaccine?

The Expanded Program for Immunization (EPI) in Pakistan is the government’s public sector program that immunizes the vast majority of children in developing countries, including Pakistan. Pakistan has been an early adopter country in Asia. In fact Pakistan was one of the first countries in Asia, to introduce both the Hemophilus type b (Hib) antigen containing pentavalent vaccine (also protects against diphtheria, tetanus, pertussis, and Hepatitis B), and the pneumococcus vaccines for all children in Pakistan with GAVI’s support. Hib and pneumococci are the major killers of children from pneumonia. Pakistan has also applied for the Rotavirus vaccine to GAVI and has been approved, so they are on track to introduce it by 2017. And as far as the rotavirus vaccine goes, once Pakistani leaders realized that 30–40% of the diarrheal disease hospitalizations in young children were due to Rotavirus induced dehydration and diarrhea, they wanted the vaccine introduced. I have worked with Pakistan’s EPI managers for a long time and they are very dedicated to both introduction of new vaccines that can save children’s lives, as well as getting as many children as possible immunized. Right now they have a huge job to do in interrupting poliovirus transmission in Pakistan, and insha’Allah we hope for success in 2017 with all the efforts that are going on.

How have you and your team managed to communicate and liaise so effectively with the Pakistani government?

That is a key question — the main thing is that you always have to have a compelling human narrative, to be able to tell a story. The numbers by themselves may not always have the needed impact with government officials. For example, for the pneumococcal vaccine we had this idea that we would not just do surveillance in the hospitals but for children who were diagnosed with severe pneumococcal meningitis, we would go to their homes 6 months later and find out what happened to them. And it was truly devastating to see how many children died at home afterwards, the permanent disabilities they suffered from such as seizures, developmental delay, blindness and deafness. We shared this kind of information with the government and told the stories of those children. And they really did understand the message — leading to the pneumococcal vaccine being added to the EPI.

What have been major barriers and challenges to working in a developing country like Pakistan? And how did you overcome these?

I have always been pleasantly surprised. Let us take Sindh as an example, which is a province in Pakistan that as you know, has historically had political dysfunction and governance challenges. I have never had our teams prevented from doing something — if we wanted space to do research etc. We have always found people to be accommodating. In my experience, the government has been very willing to work with the private sector such as with AKU. We have had a productive, successful and collaborative partnership with the government for all of these three vaccines e.g. for Hib we did Hib surveillance and then the Hib impact assessment studies, and the same thing for Pneumoccocus and for the Rotavirus vaccine. All of these studies were either in government hospitals or in the community and we always found the government to be a helpful partner.

Let’s talk about the ethics of doing research work in very poor communities — how did you manage the ‘doing research’ with actually serving/ taking care of patients who were study subjects?

I have always felt very strongly that as part of any research project you have to offer health systems support. So initially, I remember we had to keep arguing with granting agencies that we wanted a line item stating, ‘health systems support’ which would be the money that you would use to buy medicines not just for the children who were part of your study but all the children who came to the research clinics and needed them. So in the community studies that we have done, we opened primary health care centers which served the whole community, we offered free primary care, essential medicines whether they were part of our research or not. When we worked in in-patient settings we always included in the budget medicines for that hospital so that children who were not part of the study would get access to these drugs especially things that the hospital was short on. So yes, I do think there is a moral obligation to do this in these impoverished communities.

You wear many professional hats — pediatrician, public health researcher, Gates Foundation director, mother — how do you manage all these?

Firstly, I have a lot of energy for this kind of work — sadly very little for housework! And secondly, you have to know yourself and decide what to prioritize or rather de-prioritize. So I de-prioritize socializing excessively compared to the usual Pakistani standards. I am not into the socialite scene in Karachi and I don’t go out much except with close friends or family. I do not spend time on buying new clothes every season or typical shopping. I am not saying I would not enjoy it; it’s just that I do not have time for it. I have also had great help from my mother, my husband, my sister and my nanny-housekeeper — without them nothing would have been possible. I think very rarely were there children related school etc. events that I missed especially when they were young. Also, I did not travel for long periods of time when the children were growing up — not at all until my daughter was 7 years and son was 4 years old. Occasionally I have taken my son with me when he was young on work trips. A bad one was an Islamabad trip in 2005 in which the earthquake happened. I also stayed at home with them for one year each when they were babies. In dealing with the working mother’s ‘mommy guilt’ I would say it is extremely important who you get married to — your spouse has to be supportive and has to understand what career goals matter to you. If your husband is not supportive you are not going to be able to do what you want. After that you have to create an environment which allows you to work, and deal with work-life balance with a sense of humor.

Why do you think it is important for women to be able to work?

Fulfillment! I personally think that if you feel that you have more to give to society by working outside of home then you should have the freedom to pursue that. I also believe it is very important for women to be economically independent and self-sufficient.

How do you deal with disappointments in the context of your mentees/faculty you oversee?

I am very careful about who I spend a lot of time with and who I invest energy in. There are some people who are obviously very talented and you can tell right away; and there are other people who are what I call rough diamonds in that you can see their potential so are worth investing in. For me to accept someone as a mentee, it is also important to see what the other person is bringing to the relationship. What I am specifically looking for, is whether this person is energetic, driven and what will I learn from them, so we have a bilateral and mutually rewarding relationship. My whole approach to all my relationships is trust and this surprises a lot of people with whom I have worked with in Pakistan, where typically you might think it would be hard to carry this approach out. I trust people to do the right thing and this is true at work, at home, with relatives, with mentees — that is central to who I am and I believe you can truly have a multiplier effect with this approach. What I have found in all my years of working in Pakistan is that the vast majority of people are fantastic. There are very few people who I can say I have felt betrayed by. I can actually remember only one or two instances. In retrospect, I realized that I should be careful about people who flatter you and who try to create an atmosphere in which it appears that they are telling you privileged information or that they are conveying information or secrets that others don’t know and you start depending on them and can become isolated.

One thing I realized very quickly at AKU that working with the medical students was a variable experience because some were interested in children’s health and others were not — their singular focus was getting to the US. So it was much better to have people seek you out than to seek them out yourself. And also to work with residents and fellows in pediatrics. With that approach, pretty much everybody that I have interacted with and developed deep relationships with has been fantastic — some of the medical students did not do Pediatrics and went into other specialties despite my best efforts to convince them that Pediatrics was the thing to do! And that of course was fine!

A few years ago you received an email from a ‘recruiter who was hiring on behalf of a Global Health organization’ which ended up with you meeting Bill Gates and moving half way across the world! Tell us about that meeting?

When I met Bill Gates I was very impressed by his knowledge about the world, and about Pakistan along with his deep interest in child health and disease prevention. He also knew a lot about vaccines. Then during my visit, when I met all the people who were working at the foundation I developed an appreciation that the Bill and Melinda Gates Foundation (BMGF) was going to be a really special place to work at and change people’s lives for the better. That working here would allow me to touch many more lives positively than I could in my previous role. A special interest for me was to do something about typhoid and about childhood growth stunting which is related to intestinal inflammation from eating a marginal diet in the face of many infections early in life.

How would you respond to the critique of too much funding going into research and not enough into capacity development in low and middle income countries? What has the approach of the BMGF been?

At the BMGF we look very carefully at how much of the grants that we are funding are going to low and middle income countries and how much to partnering US/ western institutions. We have many programs that are capacity development programs e.g. we funded a program in India which was clinical trial capacity development. We hold many meetings like the Gates Global Grand Challenges in which a lot of developing country researchers come who have been awarded grants from the Grand Challenges program. As a previous grantee one of the best things that happened for me through consortia like the Global Enteric Multi-Country Study was not just the project which was great, but it also brought together all the other researchers from South Asia and sub-Saharan Africa. So then you had the opportunity to network with all these other potential collaborators, learn from them, learn from their challenges — which is a very important peer learning/education strategy. Also, as the Foundation engages in work focused on developing countries there are many ways in which capacity development constantly happens. Other examples would be, strengthening the regulatory environment for drugs and vaccines in developing countries, facilitating digitization of financial systems, including regulatory structures for mobile banking for the poor, small farm holder capacity development, technical and policy units for health strengthening, technical support for developing country vaccine manufacturers.

I do think to help develop a community of future scientists and thinkers in developing countries it is important to have a robust middle class and a good education system. This has happened in South Asia where there is a good talent pool of science students to recruit from and develop. In Africa this is also happening, and I am seeing more African researchers emerge, especially in areas like malaria and HIV where a lot of the research focus has been. The Wellcome Trust has put in a lot of support into their Centers of Excellence for e.g. in Kenya and Malawi. And slowly we are seeing that there is an expansion in the number of people who are doing research. From a foundation perspective there is intense engagement in Africa with projects related to TB, HIV, maternal and child health. We also do a lot of work in Kenya, Tanzania, Nigeria, Ethiopia, the Gambia, Mali and South Africa.

There is a critique of the BMGF in that it develops favorites in the funding process — how do you respond to that?

We have multiple ways of grant making, we do a lot of open calls for research proposals to which anyone can apply. In fact in the Grand Challenges you do not even have to have a track record and these are twice a year. Since we are a private organization and there are defined priority areas for us we also have targeted research proposals. So when we know we already have partners who can do the work and do it well then, to drive efficiency we can also make direct grants. I think it is really important to keep in mind who the client is/ who is the beneficiary of our work: the children and mothers living in developing countries. The partners are the intermediaries to get to the problems we can work together to solve — and we are always having to balance how to get to our goal of saving lives in developing countries in the most efficient and time sensitive way we have.

How does the BMGF keep itself updated with progress and in the work that it prioritizes?

We call ourselves a learning organization — we are constantly refining and refreshing our strategies. We are very responsive to data — not just ours but from other people too. In fact it is almost an everyday thing. We also have a high appetite for risk and failure because we know that is what we can do differently if we want transformative solutions. We expect things to fail and we expect to learn from them. We are very open to criticism — the strategy development process involves a lot of external input from researchers, program analysts etc.

You have previously said you are a relentless optimistic — how do you stay so in the face of the daily realities and depressing news from around the world?

I always look for the good that can come out of things even when something really bad happens. There can be opportunity in disaster and sometimes disaster is what it takes to change things. Also, if you read a lot then you have a healthy perspective on history and current events. You know that there are a lot of good things happening that will never be in the news. I have seen the katchi abadis that I have worked in change over time, people living in them have much more money, women have much more disposable income which they are spending on education, buying things like clothes etc. — those things you just do not see in the news. Working in these communities, you can see this year by year even in rural settings, changes that you would not read or know of otherwise.

A good story on perspective would be from when Myron Levine, a senior researcher in the vaccine sciences from the University of Maryland with whom we were collaborating with on the GEMS research was visiting Karachi a few years ago. He had previously worked in Pakistan at Jinnah Hospital in the 1960’s and I had asked him to give a perspectives talk to our young graduates about what he had learnt from his work in many different countries all over the world. People were demoralized from the frequent terrorist attacks that Karachi was going through. He showed a lot of pictures of Chile from during Pinochet’s time and how difficult it was to work there when he was doing his typhoid research there; today 30 years later Chile is a totally developed OECD country. So he was giving the message that even when things feel totally despondent and full of despair in Pakistan that 30 years later it may be a totally different situation.

What are your favorite books?

Among books that have influenced me and help me think about the world and interpret/put in context world affairs, I would say I read a lot of history and economic development books. South Asian history, Islamic history, middle-eastern history, Roman history, what leads to the rise and fall of nations. I loved reading, ‘Thinking Fast and Slow’ by Daniel Kahneman which is basically about cognitive biases in decision making. It is a hugely important book to read for people who are interested in understanding how they make decisions and how they can improve the quality of their decision making.

What would be your advice to both young men and women who want to contribute and make a change in the public health of countries like Pakistan?

I would say that you have to be driven by the moral need to return to society the incredible privilege and luck that has come your way in your life, and “paying forward” is the only way to make the world just, reduce inequality, and create opportunity for others, especially children.

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Note: *Claire Panosian Dunavan: 2008 President of the American Society of Tropical Medicine and Hygiene, ex-chief of Infectious Diseases at LA County-Olive View Medical Center, ex-Director of Travel and Tropical Medicine at UCLA, she has been a UCLA professor, clinician, and teacher since 1984; Samuel L. Katz: Pediatrician, infectious diseases specialist, ex-chair of Pediatrics at Duke Children’s, co-inventor of the measles vaccine; Barth Reller: Pathologist, director of the Clinical Microbiology Laboratory at Duke; Don Goldmann: Pediatrician, infectious diseases specialist, Professor in the Department of Immunology and Infectious Diseases at Boston Childrens’/ Harvard Medical School.

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1. http://www.gatesfoundation.org/What-We-Do/Global-Health/Enteric-and-Diarrheal-Diseases/Strategy-Leadership/Anita-Zaidi

2. http://www.childrensprize.org/blog/az_interview_cp2013/

3. http://www.childrensprize.org/blog/driving-for-results

4. J Pediatr. 2013 Jul;163(1 Suppl):S86-S91.e1. Mortality and neurodevelopmental outcomes of acute bacterial meningitis in children aged <5 years in Pakistan. Khowaja AR et al

5. J R Soc Med. 2005 Nov;98(11):492–3. Unwanted foreign doctors: what is not being said about the brain drain. Shafqat S, Zaidi AK.

6. N Engl J Med. 2007 Feb 1;356(5):442–3. Pakistani physicians and the repatriation equation. Shafqat S, Zaidi AK.

7. Lancet. 2013 Jun 22;381(9884):2156. Anita Zaidi: promoting newborn and child health in Pakistan. Mushtaq A.

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