Proximity Matters in Global Health with Hema Magge, MD

• Magge grew up in Cincinnati, Ohio as a first generation American. Her father came to the U.S. in 1959 from rural southern India, and her mother came shortly thereafter. Magge says her father faced struggles but had the “privilege of living the American dream.”
• She felt lucky from a young age that she had a secure upbringing and excellent schooling, because she knew “there were a lot of people who didn't have that luck and that we were all at the same time, no different from each other.” 
• Soon after high school, Magge approached her career with the intention of being a part of social justice. “I knew I wanted to be part of making the world a more fair place where everybody had the opportunity to live healthy, happy lives. And I knew that that was not the case for some people,” she says. 
• This pursuit led her to Harvard University where she studied political science and government. After college, she obtained funding to work with a group of social workers who were running a child violence prevention organization in Cape Town, South Africa, in 2000, at the height of the AIDS epidemic. This experience sparked her interest in global health.
• She learned that to make an impact in Global Health she needed to “be proximal, listen and learn first before trying to solve other people's problems, and see them as shared issues.”
• Magge returned to the United States and attended medical school at the University of Pennsylvania. After medical school, she completed her residency in pediatrics at the University of California, San Francisco. During her residency, she worked with Partners in Health, a non-profit organization that provides health care to people in resource-limited settings. After her residency,  Magge moved to Rwanda to work with Partners in Health. She led the pediatric program at a rural district hospital. In this role, she worked to improve the quality of care for children in Rwanda. She also worked to build the capacity of local health systems to deliver high-quality care.
•  She believes that quality improvement is a set of tools that can be used to improve the health of people in resource-limited settings.
• After five years in Rwanda, she moved to Ethiopia as executive director of the Institute for Healthcare Improvement.
• Much of her work and research has revolved around neonatal health. This was not her intent, but she says the data and the need led her to address neonatal mortality and bring innovative care into that space.
• While doing this work in Africa, Magge and her husband, also a global health physician, started their family, raising two daughters. Magge says she sees her global health work as a culture, and was lucky enough to find a partner who shared a similar worldview.  
• When it comes to having a family and a career in global health, Magge says you have to “think big in both realms and then figure out periods of time in which one may dominate and another may step back, but then you may be able to switch that up.”
• She likes to think of life in five year chunks and to “stay flexible and open-minded and seek opportunities and be open to them when they come your way.”
• Throughout her time in Africa, Magge became an advocate of kangaroo mother care, a low-tech  intervention that is described as prolonged skin-to-skin care between a baby and their mother, and exclusive breastfeeding that leads to shorter hospital stays and duration. 
• With proximity and implementation, she saw how kangaroo mother care could be incredibly empowering and truly transformational when it was implemented well. But she says implementing this intervention in a complex system is not simple. “It takes a lot of time and effort to support a mother and to really build the confidence and comfort with keeping a baby skin to skin for long periods of time.”
• Her advice to people who want to pursue global health is: immerse yourself and be open and flexible.

Rob Murphy, MD [00:00:06] Welcome to the Explore Global Health Podcast. I'm Dr. Rob Murphy, executive director of the Harvey Institute for Global Health here at Northwestern University Feinberg School of Medicine. Today's guest knew from a young age that she wanted to make an impact on the lives of children and families. That led Dr. Hema Magge to pursue a career in medicine and global health. She is now a pediatrician and senior program officer for the Bill and Melinda Gates Foundation, focusing on global newborn health. She has devoted her career to addressing global health inequities and creating equitable solutions to improve the welfare of women and children. Hema joins me today to talk about career, including her decade at work with NGOs in Africa and her ongoing research on bridging the delivery gap in child and newborn health interventions in resource limited settings, quality of care and pathways to scale. Welcome.

Hema Magge, MD [00:01:01] Thank you.

Rob Murphy, MD [00:01:02] Let's start at the beginning in Cincinnati, Ohio, where you're from. Tell us, what was it like? Did your childhood have any impact on the work you do today? Tell us about how you came from Cincinnati.

Hema Magge, MD [00:01:14] I think I defined my childhood as really being the child of immigrants. I grew up in a family where my father came to the U.S. in 1959 from rural southern India, and my mother came shortly thereafter and put really simply, he had the privilege of living the American dream. Ostensibly, there are many aspects of that story that are a struggle. He came without very much money in his pocket, lived in a YMCA, got mugged in Central Park, had all the stories. At the same time, when I asked my father, Wow, you sacrificed so much. He doesn't see it that way at all. You know, he says, I was so lucky I got to do what I wanted to do. I wanted to have these opportunities. I wanted them for myself and my kids. And I was able to work hard to get them. And if you think of it from that sense, that was a huge privilege. And so when you compare what my parents went through and experience, yes, there were many aspects, were incredibly hard, but they had the choice and the opportunities to make decisions with conscientiousness and intentionality. And I think that growing up in the U.S., hearing those stories, feeling that dream, and then learning what I sought to learn about what poverty in the U.S. was like. And it was very different. And I don't think I had a name for it. Now we have language to describe, but things like implicit bias and systems failures and injustice that is built into structures and structural violence of poverty. But I didn't know that yet at that time. I just knew there was something there that I wanted to understand better. I just had this general sense that I had what I had, not because I earned it. I had it because I got lucky and that there were a lot of people who didn't have that luck and that we were all at the same time no different from each other. And that with that came some sort of obligation to try to understand and learn from each other and very simply try to contribute something meaningful to the world. When I think back to growing up in suburban Cincinnati, in a fairly well-to-do neighborhood and going to a really wonderful school, you also know Cincinnati is a city rife with a history of deep racial tensions, segregation, violence. And so if you seek it, there is so much to learn. And so I felt like that was the journey I was on, and I just knew I wanted to learn more about that big, broad world out there.

Rob Murphy, MD [00:03:50] Well, since you mentioned that you went to good schools, I understand that you were an excellent student in high school. You were a presidential scholar and you went to Harvard and you studied government, and then you decided to pursue medicine, specifically pediatrics and global health. So I think probably one of the biggest questions I get from students and residents and all the trainees I work with, both in Africa and in the United States, is what is the pathway. They know they want to do this global work, but they don't understand the pathway. And I asked this question to, of course, everybody that comes on this podcast, and believe me, there is no one pathway, that's for sure.

Hema Magge, MD [00:04:32] The way I approached it was very intentionally. So I knew that I wanted to be part of social justice. I knew I wanted to be part of making the world a more fair place where everybody had the opportunity to live healthy, happy lives. And I knew that that was not the case for some people. And that designation of who those some people are is also not by accident. There are reasons why some groups of people are more disadvantaged and that those are historical. That's how I would describe my maturity level as an 18 year old with feeling like I want to get into this field, I want to understand it better. I want to be part of something bigger, but I need to learn. And so I thought before figuring out a career path what vocation I would take in that big, broad field, I wanted to first understand what created those social determinants of health. So how politics and policies and the people who hold those powers, how those actually intertwine and interact to affect the lives of real people and ultimately affect their health and well-being in a broad sense. So I had fairly strong inclination that medicine and health care would be my way of connecting into this mission. But I wanted to situate that in a broader understanding of society and politics and culture. And so that's why I actually went in to study government at Harvard. But I started my pre-med work from the beginning, actually, because I wanted both tracks to complement each other, and I felt like it would help me really solidify if that was truly what I wanted to do. And ultimately I decided medicine really did feel right to me because at the end of the day, while my vision and impact dreamed big, I knew that where I derived my daily joy was just in everyday interactions with individual people and that there was just something so special and an incredible privilege that came from that doctor patient relationship and that ability to be with someone, to sit with someone and to hear them and be in solidarity with them at a time of vulnerability and real need and to hear their stories. And on a practical level, I thought if all these big dreams don't come true, I know that I would be super happy just being a doctor, taking care of kids, taking care of families. I felt like that would just give me joy and purpose every day, and I have never regretted that. And I would say that's only deepened and strengthened. And I feel that anything I've done in public health and systems, work and research, all of this is only as good as being grounded in the real lived experience of patients and their families.

Rob Murphy, MD [00:07:19] Immersing yourself in global health can be very intimidating, but that's exactly what you did. And during your residency at UCSF, you went to Africa for the first time as a physician. What was it that pushed you into the global sphere? What triggered the global component for you?

Hema Magge, MD [00:07:35] It really started more in college as I deepened my studies in political science and comparative politics, international human rights, I really just got deeper and deeper into the global nature of social justice and just how shared these issues are across countries and the connectedness of humanity and the commonality of these issues no matter where you live. And then just my general curiosity, I wanted to see more of this world than I could learn from other people and cultures. I remember in college and then again in med school, there was nobody in front of me at career panels doing what I wanted to do, but I knew that there was something there for me. My sense was that the people who are doing the work I want to do are not here at Harvard speaking on my career panel, and they're not here at UPenn in my med school panel. They're out there in the world doing the work, so I need to go find out. So in college, after my senior year, I decided to not apply to med school yet and to try living in Africa in somewhere where I might be able to find some mix of need, an opportunity and learning and where I wouldn't be a burden. That was, those were the things I wanted to do. I was like, I don't want to start a project. I remember looking for funding opportunities. All the funding opportunities I saw at that time wanted to see my new great brand new fancy idea, and I was just like, I don't know enough to have my own innovative idea. I'm just a kid who has studied at really great schools, but this is not my community. Like, how would I know what solution is needed? And that just was my instinct. Now I realized that that's actually a real need is to have that ability to really be proximal, listen and learn first before trying to solve other people's problems and see them as shared issues. And then I finally was lucky enough to have a wonderful mentor in college, Sean Palfrey, who is an amazing pediatrician at Boston Medical Center. And he connected me with an old friend he had at the Red Cross Children's Hospital in South Africa in Cape Town, who connected me with a small group of social workers who are running a child violence prevention organization in townships and areas around Cape Town in South Africa. And so I went and volunteered with them. Instead of applying for one of these more prestigious fellowships, I was really lucky to get a Public Service Fellowship, which provided me the living stipend. I needed to then be able to volunteer with this group of social workers. And that was really my spark. That was my foundational experience living in Cape Town in South Africa in 2000, peak of the AIDS epidemic. And that was where I got to see and live that intersection between politics, policy, health and community organization and activism. And that was it. I was sold from then on.

Rob Murphy, MD [00:10:27] Talk about jumping in with both feet. You spent a whole decade in Africa after South Africa, with five years in Rwanda, with Partners in Health, and then you moved to Ethiopia as executive director of the Institute for Health Care Improvement. Tell me how these experiences impacted you and what did you accomplish in those roles?

Hema Magge, MD [00:10:48] I think what I learned early on was the importance of proximity and immersion and learning and that those were shaping me and helping my understanding deepen and evolve. So after my time in South Africa, I was convinced I wanted to be a doctor, and this is what I need to learn how to do and to do it as best as I can. So focused on med school, focused on residency, and then after residency I thought, Well, if I want to do anything in co-designing programs with communities, I'd also want to be able to understand their impact and understand if what we're doing is actually making a difference, positively or negatively measuring unintended consequences. So I ended up doing a general Pediatrics fellowship also personally. My partner in crime was finishing his residency in Boston, so I thought, okay, we need to start being in one place on one side of the country. So I moved from San Francisco to Boston. I knew that I wanted to do work very proximately, so I figured this is a good way to build the skills I need to then be able to find a position living and working in the communities I wanted to serve. So I did my fellowship and got my master's in health services research. I think what I was really trying to study at the time that I didn't have a name for and didn't really have the language for yet was implementation research and implementation science really designing rigorous implementation with this embedded measures to understand the intended and unintended consequences of the work you're doing. And so then in that process, I was able to connect with Partners in Health. There are many organizations doing incredible work. I just happened to have the opportunity to work with one of them, and I had the opportunity to do my own AIDS research, fellowship and research at a Partners in Health site in Rwanda. Again, I was just really trying to make sure and recognizing that while I may have something to contribute, it is also very much work for other people to teach me. So I was just really trying to craft an opportunity to learn and immerse that would really be bi directional and to minimize the strain on others. And that's a real delicate navigation of trying to really listen and hear what is needed and then walk that back with what can I do that maybe can help meet that need. So that was how I designed that research work. And then that naturally parlayed into a position with Partners in Health full time. So my husband and I moved to Rwanda, where I was able to lead the pediatric program. My husband carved his path and infectious diseases work there. And that was just incredibly foundational for me. That provided the opportunity to really immerse lives side by side with doctors and nurses in a rural district hospital and be part of an organization that had a long standing partnership in that community, both with the health facility staff and the government and be part of the country's rebuilding effort after the genocide. It was about being part of something bigger, not trying to do my own thing. And within that, that created the opportunities to dream and innovate and really build out programs that met the needs of children. The things and areas that I ended up focusing on technically were not necessarily things that I would have predicted. I never would have thought that I'd be focused so strongly and squarely on neonatal health. But that really came from the data and the needs that presented themselves. So I said, okay, I thought I was going to be working in adolescent health because that's what I was interested in. But at the time, the ministry looked at their child survival data and really were finding that neonatal mortality was the area they wanted to tackle and they wanted patches help and really bringing innovative care into that space. There were a sequence of learning steps that move from there.

Rob Murphy, MD [00:14:28] You mentioned your family and a lot of younger trainees, as they're getting into the field, they wonder how can you balance your personal life and raising or having a family while pursuing this career in global health? This is a very common question, and it's an important question. How did you manage that?

Hema Magge, MD [00:14:45] It is a really important question. Comes up all the time. I would say I was really, really fortunate. People think about these things different ways. So I say this with no judgment. This was just what resonated with me, which was that I did not see personal and professional as being. Seeing this divide. I remember being in med school and there being panels on work life balance and I somehow just really didn't feel comfortable at them. They felt like a false dichotomy and maybe it was just immaturity that I just wasn't ready to accept that I was going to have to make any compromises. I just felt like, I don't want to compromise yet. I want to go full speed ahead, both tracks and recognize that I can't control what's going to happen in the world. And if I were so blessed to have all these things, then that's a privileged decision to kind of figure out how to make them work. But I'm not going to stop myself before I have a problem. And to me, that felt very personal. It didn't feel like work that was separate from what I wanted in life. It was the life I wanted. I think then where it came intentional, was I saw my work as a culture and I was lucky enough to find a partner who shared a similar worldview and how he wanted to live life and pursue a career in health and social justice. And so we were able to craft that path together. But I realized not everybody has that option. And then I think it's really about choices and figuring out what your priorities are. But I do think that students are often face and maybe this has evolved since the time I was a student, but this false dichotomy of work and life that sort of puts them as opposition from the start. I also say that knowing you can't have everything all the time, but I think setting them up at the outset as being in opposition to each other is also not true and doesn't have to be true. And it can also be misleading. I think people have the opportunity to think big in both realms and then figure out periods of time in which one may dominate and another may step back, but then you may be able to switch that up. Something that's helped me personally as they try to think of life in five year chunks. We're lucky to have that opportunity. And then that gives you flexibility because as you said, there is no paved path. If we were really trying to solve for impact, then you've got to stay flexible and open minded and seek opportunities and be open to them when they come your way.

Rob Murphy, MD [00:17:07] Let's pivot a little bit and talk about your research.

Hema Magge, MD [00:17:11] Well, at the moment, right now, I'm not actually leading research because I've moved into this donor role. So I can tell you a little bit more about the research that I was doing, which still is very related to the work I'm able to lead at the Gates Foundation now. But my research, based out of the work I was leading in Rwanda and then moved on into Ethiopia, where really trying to ask pragmatic questions that helped answer the needs that were determined at the outset. So as I mentioned, neonatal mortality was determined to be a really high priority in Rwanda. And so the government said, look, we've got women birthing in facilities, we have high facility birthing rate, yet we're not seeing the reductions in mortality. Why is that? So then that led naturally to quality of care, to figuring out what is happening in those contacts with the health system. And so that was sort of where we dove in our programmatic work of really trying to design and understand ways of improving quality of care, but then building in the research questions to make sure that we were answering those questions with rigor and in a way that would be informative to the country for being able to strengthen and scale up their health system programs and showed that is really the field of implementation research. There are many ways of describing it, but that was the bucket of questions. So really less on the what to do, but more on the how to do it, how to implement, how to make things work in the real world, in the real health system with the real humans that you have in those health systems to reach women and children with the life saving interventions they need in a way that is accessible, that is respectful and gives them value. So I ended up doing quite a bit of research on implementing a district wide approach to reducing neonatal mortality in Rwanda, which was a combined clinical quality and health system improvement approach. And then when I had the opportunity through collaborations with at the time AHIP Institute for Health Care Improvement that was doing similar work in Ghana and Malawi at the time, we started connecting to kind of build a community of practice amongst implementers in Africa and then through connecting with them, had the opportunity to try to do fundamentally very similar work in Ethiopia, but now at a much larger scale, in a much bigger country with a new set of issues. And so to me that was an opportunity to learn more about that kind of science of scale. And so that's where my research started to move more. So with both, again, programmatic work, so that building the program and intervention design, but getting more into questions of how do we really scale up health system approaches and design the research to answer questions that the government needs answered to be able to lead the scale up they need? Because this is a country of 100 million people and over 800 districts. So figuring out how to make things work in one district is not going to be enough. It really have to be designing for that large scale from the beginning and paving out that stepwise pattern. 

Rob Murphy, MD [00:20:12] I understand that you're a big advocate of kangaroo mother care.

Hema Magge, MD [00:20:16] Yes.

Rob Murphy, MD [00:20:16] Great intervention, low tech and life saving technique that has saved countless babies around the world. I think it's just an example of what you just described, the whole process. Could you just elaborate a little more on focusing on kangaroo mother care?

Hema Magge, MD [00:20:29] Kangaroo mother care is an intervention that is basically described as prolonged skin to skin care between a baby and their mother and exclusive breastfeeding. And that together that tends to lead to shorter hospital stays and duration. And the evidence base is extremely strong around. KMC And it really started many decades ago in Colombia based on observations of Dr. Edgar Rays and then has evolved over time to become more of a mainstream approach and intervention. So KMC is such a fascinating thing. When I first started out as a young pediatrician in Rwanda, I was skeptical. I thought, this is a solution that is being pushed by global health actors only in poor countries. It's not being pushed in the U.S. it's not being pushed in Europe, at least at that time. Is this just a poor solution for poor countries based on a scarcity mindset and not based on a justice framework? That is how for some it originated. But I think with deeper nuance and learning and again, this is what you only learn through proximity and working through it and implementation. I saw how kangaroo mother care could be incredibly empowering and truly transformational when it was implemented well. And that is a complex system. And I think that part of why it was low in implementation is that a lot of the messaging was very oversimplified. It's low tech, it's simple, it's cheap, but in reality it actually takes a lot of time and effort to support a mother and to really build the confidence and comfort with keeping a baby skin to skin for long periods of time. And that takes a lot of social support. It means that you also have to make your hospital a place that a woman wants to stay. You means you have to feed families. That is not standard in many resource constrained environments, and you have to have visiting policies that allow women to have social support from their families. Again, not the standard in neonatal units across Africa, which were often made copy and pasted from high income settings where it was the opposite. No one's allowed in, no mothers, no fathers. Letting mothers in became a concession. So we are guests in the care of our children. So KMC is transforming that. I think what has been very exciting and now really relates squarely to the work I lead at the Gates Foundation has been that the science has evolved and we've now been able to demonstrate its efficacy not only in more stable, pre-term, low birth weight infants, but now even in the sickest and smallest of those babies. And that is now the true transformation and mission that awaits us is transforming health care delivery systems to ones where moms and babies are never separated and ones where they support a baby staying in kangaroo care even while they're getting all of the other intensive care that they may need, like CPAP, oxygen, IV fluids and the like. That's the new frontier. While we're focused on low and middle income countries, this is also incredibly impactful in high income countries, and that's, that equalizing power of KMC.

Rob Murphy, MD [00:23:49] You collaborate with Lisa Hirshhorn here at Northwestern. We recently hosted you here as part of the Harvey Institute for Global Health Seminar series, and you presented a talk called The Global Quality Chasm. What is the role of quality improvement in advancing global maternal and newborn equity and scale? It was a great presentation. We thank you very much. Can you tell us a little bit about that work that you presented?

Hema Magge, MD [00:24:14] You know, I think that was bringing together these questions around a lot of the topics. We've talked about maternal newborn health. What is it that is needed to bring high quality care to those who need it the most and where they are as well as then the system? So you've got the interventions, the things, the what you do, and then the how how do you deliver them to families and patients. Those are the health care systems. And so bringing together the clinical content within the health systems improvement work, and that's where it all came together across experiences in Rwanda and Ethiopia. Quality improvement is a set of tools, but it has to be expanded to really be more expensive to understanding the needs in resource constrained settings. So not just micro-level cycles of PDSA improvements, but really using data. To inform more Mizo and macro level systems planning, governance, infrastructure support, financing and the like. All of those building blocks of health systems.

Rob Murphy, MD [00:25:13] And one final question for this morning is what advice would you give young people who want to embark on a career such as yours? What can they do to prepare themselves best for a career in global health?

Hema Magge, MD [00:25:26] That's easy. Immerse yourself. Try not to get too far in your thinking of what you want to do before listening to others and finding out what is really needed. And then figure out, you know what you love. What are your gifts? What are your talents and how can they be of use? That was the greatest advice I ever received, and that has been a North Star for me in my career is really that immersion and trying to be open and flexible. And it has never served me wrong. And that is definitely my number one piece of advice to people who are interested in global health.

Rob Murphy, MD [00:26:01] That's great advice and I can't thank you enough for joining us today, Dr. Hema Magge at the Gates Foundation. Thank you very much for sharing all your experiences and insight. Incredibly valuable. Thanks again for joining us today.

Hema Magge, MD [00:26:16] Thank you. Thanks so much for having me.

Rob Murphy, MD [00:26:24] Follow us on Apple Podcasts or wherever you listen to podcasts to hear the latest episodes and join our community that is dedicated to making a lasting positive impact on global health.