Implementation Science in Global Health with Nadia Sam-Agudu, MD

• Born and raised in Accra, Ghana, Sam-Agudu came to the U.S. for college with the goal of becoming a medical doctor. Her desire to have a career in medicine stemmed from several bouts of malaria she had as a child and realizing that there was a need for more physicians to treat African children.
• As part of her education at Mayo Medical School, where she earned her MD, Sam-Agudu was required to complete a research project. She had little interest in pursuing research as a career, but she was soon introduced to her mentor, Chandi John, MD, MS, who helped her develop her research skills and guided her in focusing on malaria research in Uganda, a topic close to her heart. 
• In 2010, she joined the Epidemiology and Prevention Division of the Institute of Human Virology (IVH), which is  part of the University of Maryland School of Medicine, and she was based full-time in Nigeria for more than a decade. Among other public health activities, Sam-Agudu’s time there was spent making sure National Nigeria Guidelines, CDC directives, WHO guidelines and any new emerging evidence for children living with HIV and for prevention of HIV among children were implemented.
• It was during Sam-Agudu’s time in Nigeria, working on public health initiatives, that she discovered what implementation science research was and how she could improve health on a population level. She says, “closing the 'know-do gap' and making sure that evidence was going to benefit people at the population level, really speaks to equity for me.” She is now a primary investigator on several grants funded by WHO, the American Academy of Pediatrics, and the NIH that include the prevention of mother-to-child transmission of HIV and adolescent HIV.
• Another topic Sam-Agudu has recently published on is decolonization in the field of global health. She emphasizes the importance of dismantling systems that uphold white supremacy in knowledge production and ensuring the inclusion and recognition of knowledge and expertise from diverse backgrounds. 
• She says decolonization is not just something the Global North needs to address but the Global South as well. She says it is important for the Global South to look at its own roles in colonial behaviors and to make sure that they are not perpetuating harmful actions as well.
• Sam-Agudu’s advice to students who want to pursue a career in global health is to “be fearless.”  She says it is in that space that people can find the “thing” that is right for them.

[00:00:00] Rob Murphy, MD: Welcome to the Explore Global Health Podcast. I'm Dr. Rob Murphy, Executive Director of the Havey Institute for Global Health here at Northwestern University Feinberg School of Medicine. Today's guest is a driving force in using implementation science to improve the health of children around the world. Dr. Nadia Sam-Agudu has built a career focused on infectious disease prevention in children and adolescents, particularly in West and Central Africa. We are thrilled to have her on the podcast today to talk about her path to global health and her goal of improving the health status of children living in resource limited settings. Dr. Sam-Agudu is the Director of the Global Pediatrics Program at the University of Minnesota Medical School, where she also serves as Professor of Pediatrics in Infectious Diseases and Associate Dean of the Center of Multicultural Affairs and Engagement for Medical Students in the Office of Diversity, Equity, and Inclusion. Welcome Nadia.

[00:01:06] Nadia Sam-Agudu, MD: Thank you, Rob. Happy to be here.

[00:01:08] Rob Murphy, MD: We are very happy that you're here. So you were born and raised in Accra, Ghana, then came to the U. S. for college and your medical training. But from a young age, you had plans to pursue a medical career involving African children. Can you share a little more about this early part of your career with me, and what led you from Ghana to the U.S.?

[00:01:29] Nadia Sam-Agudu, MD: So, this was really at an early age, between 8 and 10 years of age, and I remember one of my several bouts of malaria where I had been taken to the hospital, sitting waiting to be seen by the doctor. And there was a long line of people waiting to see this doctor. And, my father happened to know the doctor in question. So I remember, yes, I was ill, but I could see people in the line who were more sick than I was, walking past people who had been sitting probably for hours and going into the consulting room with a doctor and him doing an exam and giving me my treatment for malaria. And I didn't think it was fair that I could get in and walk in and see the doctor and walk past so many people who obviously had been sitting there for quite a while waiting to see him. So I said in my, you know, sort of childlike mind that there must not be very many doctors in the country. So what I was going to do was train to be a doctor so that I could add to the number of doctors so that this many people, including children, would not have to wait this long to see a doctor. So that's how I got to thinking about a medical career.

[00:02:33] Rob Murphy, MD: Nadia, was any other members of your family in the medical field?

[00:02:36] Nadia Sam-Agudu, MD: Actually, I had one uncle, who was much older than me, who had left Ghana to go to Canada to be an obstetrician. And then one distant cousin of my mother's. And the rest of the family was really businessmen and women.

[00:02:51] Rob Murphy, MD: So let's talk a little bit about your medical training. So you did your medical training at Mayo Medical School and you said at first you had a really just a little interest in research. And of course that's turned around. So, what got you turned on to research, and specifically global health research?

[00:03:07] Nadia Sam-Agudu, MD: Given the scenario I explained to you earlier, I wanted to be a clinician so badly, right? Go in clinic and treat patients and not have a long line of people around the hospital. And then my idea, and I don't remember quite where I got these ideas, was that people who did research were really sort of arrogant, stuck up people, who weren't really clinicians. Because there was a clear demarcation between researchers and clinicians in my mind, that there was no such thing as a clinician scientist, right, which I am today. And so for me, I was either going to be a clinician or a scientist, i. e. a researcher. And I had in this my mind that they were not friendly people and because they didn't really do patient care. And so I was like, well, I don't want to be that. And I don't want to do research. And at that point, I thought research was only where you did, sort of, wet lab work. People who sit for hours in a dungeon somewhere and do lab tests and things like that in a lab and really didn't talk to anyone. And so I had this aversion to research because in my mind, there was only one type and you were either/ or in terms of clinician versus researcher. Now, what happened was I got into Mayo Medical School, obviously a very good medical school. I loved my time at Mayo Clinic. But one of the things I realized in year one, was that all medical students were supposed to do a research project, and Mayo was requiring medical students to do this at a time when a lot of med schools actually weren't requiring that. And I was like, of all the med schools for me to go to, why does this one have to ask me to do research? Something which to me was just completely alien and wasn't in my mind at all. I was like, I don't want to not be friendly. And If I'm going to do research, then it has to be in a topic that I want to do and among a population that I've really caught my attention for many years. And so I harken back to my childhood of having malaria myself and seeing lots of other kids having malaria sitting around the hospital waiting to be seen. So I decided I was going to do a project in malaria research in Ghana.

[00:05:02] Rob Murphy, MD: So, let's go on with your education. You stayed in Minnesota for your pediatric residency and an infectious diseases fellowship at the University of Minnesota in Minneapolis. And it was there that you met your primary mentor, Dr. Chandi John, whose research focused on pediatric malaria immunology in East Africa. Can you tell us how Dr. John helped you develop your research skills?

[00:05:26] Nadia Sam-Agudu, MD: Yes. So I just started my fellowship when he actually came over to Minnesota from Case Western to interview for his job. And at that time, there were really no Peds ID doctors in our division who were doing international type of work or global health. And knowing that I wanted to focus on malaria, obviously, I wasn't going to find patients to work with malaria in Minnesota. I had to go and work home or work with somebody who was working in an African country that had malaria. And so I was at that point thinking I might have to cross over to adult infectious disease and find somebody there because there were few people there who are doing some of this work . Then comes Chandi to interview, and I'm like, this guy has to take this job just to mentor me because I have nobody in our division who is doing it. I needed him. And so I spoke to him and he's like, well, if I do come here, I have projects in Kenya and Uganda and you can pick whichever one you want to do. And I was like, "Oh my gosh." So long story short. Fortunately for me, he took the job. I was his first clinical fellow that he mentored, and I always claimed that position and I decided to go and work on cerebral malaria in Ugandan children at Mulago Hospital at Makerere University.

[00:06:39] Rob Murphy, MD: Tell us a little bit more about those early years of your career. What were some of the challenges you faced as you tried to carve out your niche in global health research?

[00:06:49] Nadia Sam-Agudu, MD: You know, today you have even med students who already have maybe some projects who have written some abstracts or even papers and have mentorship into residency before they even pick fellowships. I really didn't have much research mentorship until I met Chandi. I did do some work, as I said before, in Ghana, in pediatric malaria, where I was fortunate to work at the Noguchi Memorial Center for Medical Research. But that was for a short stint of time for med school. And so between the time that I finished that project and met Chandi in year one of fellowship, I had absolutely no research activity. And so mentorship was a big gap there. So, by the time I met Chandi and sat down with him, showed him my CV and he's like, what have you done? And I said, not much. I have one abstract from the work that I did in med school and that's about it. And so he's like, okay, we quickly need to catch you up into doing this. And also being a clinician, doing research, doing translational research that they call bench to bedside type of research. I had to learn how to pipette. I had to learn how to run PCR gels because we're doing PCR work in Uganda. I had to learn all of that. And I will thank all the PhD students and postdocs who helped me survive lab work as a clinician.

[00:08:02] Rob Murphy, MD: In 2010, you joined the Epidemiology and Prevention Division of the Institute of Human Virology, often referred to as IHV. This is part of the University of Maryland School of Medicine. But you were based full time in Nigeria. You were as a Senior Technical Advisor for Pediatric and Adolescent HIV at the Institute of Human Virology in Nigeria, Abuja. And you were there for more than a decade. Tell us what it was like living in Nigeria for 10 years in this project.

[00:08:31] Nadia Sam-Agudu, MD: I'm still there actually. I retain my affiliation with the Institute of Human Virology Nigeria, where I continue to provide technical support for implementing PEPFAR funded programs for children and adolescents. And I continue to conduct research and to train others. We now have an International Research Center of Excellence at the Institute Virology, Nigeria. So I serve as senior research faculty as well as a senior technical advisor. Granted, the amount of time I spend doing those activities, especially the public health one, has decreased significantly because my research portfolio has expanded. But I maintain that affiliation and those activities. I just spend less time in Nigeria and more time in the U.S. So I started working in Nigeria in 2010. I was hired by the IHV of the University Maryland, Baltimore, but to work full time in Nigeria. So, I lived there full time, I still had my family in Ghana, I still had my HQ headquarters in Baltimore. And so I was doing this sort of merry-go-round of these three places, but I spent most of my time in Nigeria. And my main job as Senior Technical Advisor was really to provide technical support to the Institute of Human Virology, Nigeria, IHVN, which is a PEPFAR Implementing Partner, IP for short. And so, I was hired to fulfill the role of helping to provide technical support to run the pediatric program. And, back then it was pediatric, as in under 14. But over time, we realized there was a gap in terms of adolescents. So it became pediatric and adolescent from 0 to 19. And so that was my charge. And at the time I started, there were about 4,000 children in adolescence in the program. And as of now, we have about, say 10,000 that we are working with: children, adolescents, and young people. And CDC was funding us with PEPFAR funding for that work. And my job was to make sure that National Nigeria Guidelines and CDC directives, as well as incoming WHO guidelines. would sort of harmonize and make sure that we were implementing according to those guidelines and any new emerging evidence for children living with HIV and for prevention of HIV among children. So I did do some PMTCT work, obviously, naturally, if you are doing pediatric HIV work, you have to do PMTCT work, which is prevention of mother to child transmission of HIV work. So prevention and treatment of HIV among children. And it's been a delight. I learned so much as a clinician/ emerging clinician scientist. I also got public health skills, and I would say interestingly, I don't have a master's degree in anything.

[00:11:02] Rob Murphy, MD: I don't either.

[00:11:02] Nadia Sam-Agudu, MD: I have an MD and a pediatric ID fellowship, you know, and a CTROP certificate, CTROP med certificate. But I have public health program implementation skills as well as from the public health work is really where I revived my research interest. Because then I would see within the program the gaps that needed to be filled that maybe the program couldn't fully address. I said, I'm going to write a grant about this. And address it in a way that I think makes most sense. And somehow I started to be successful in writing grants. So, that's how things evolved from there.

[00:11:36] Rob Murphy, MD: That's a really excellent point, because a lot of younger students and trainees now, you know, they think, "oh, I have to have an MPH or I have to have a master's in global health," or I have to have this or this or this. And you just did it all as part of your MD and your infectious diseases training, which is actually the way I did it. Very few people had an MPH, and now really quite a few people do. But you don't have to have it, you're working in the field and you know infectious disease. Let me ask another question about Abuja. I'm fascinated. How did you like living in Abuja?

[00:12:03] Nadia Sam-Agudu, MD: It's quiet. It's not Nigeria. It's quiet. That's what they'll tell you. That's what Lagos people would tell you. "Oh, you people think you have traffic. You must be joking." There's no traffic in Abuja. Really what I did was I largely just worked. Every now and then I might have a social event. And I would still sort of rotate to go see my family in Ghana. And then when there needed to be a meeting or a retreat at the IHV in Maryland, of course, I would attend those as well. And then started to attend scientific conferences as my research portfolio grew, to present work and then started to do more beyond public health work started to actually informally and then formally mentor young Nigerians, whether they were master's holders or undergraduates, and then the MDs and the PhDs. And now I have a training grant to formalize all of those after hours mentoring I was doing.

[00:12:55] Rob Murphy, MD: As a principal investigator now, your grants include prevention of mother to child transmission of HIV and adolescent HIV studies funded by WHO, the American Academy of Pediatrics, and the NIH. You've concentrated your work in West and Central Africa. Can you tell me a little bit about specifically your projects and why you' ve decided now after all this training and everything to stay focused in West Africa?

[00:13:21] Nadia Sam-Agudu, MD: I was working in Uganda and that was great, a very rich and strong research environment in which to work. And I was grateful for that, particularly as an African. But then with my own career evolving and having worked for year after year in Nigeria and really looking at the bulk of research that was done, say, generally in global health, but particularly in HIV, there's disproportionate productivity of research with respect to HIV, you're really filling the blank, health condition affecting several African countries. There's way more happening in East and Southern Africa than West and Central Africa. And there are many reasons that we can have a whole other conversation on, but I thought that part of it was also that we needed to have better research systems or research infrastructure. And what I could contribute to that was actually capacity building, skill building, leadership in research, quality research, well-trained researchers, who don't necessarily necessarily have to leave the region or their respective countries to get trained, or not have to leave permanently at least. And so I decided that I had returned, say, after my training in U.S. to work in Africa or in African countries. But then with time, I shrunk that to focus on West and Central Africa, because we are lagging behind the rest of the continent. And there are bibliographic studies that have reported this, in research productivity and in researcher per capita of the countries in our region. So I've decided to focus and contribute to that.

[00:14:49] Rob Murphy, MD: Your overarching research goal has been to conduct studies that generate impactful evidence for equitable and sustainable health systems and policy changes. You've been quoted that implementation science methods are well suited to achieving this goal, especially in resource limited settings. Can you expand on that a little bit? Why is implementation science a good match for basically what you're trying to do in global health?

[00:15:14] Nadia Sam-Agudu, MD: Right, and some of the buzzwords you've heard with implantation science are the "know-do gap." Closing the gap between what we know, evidence that has been generated, and what we are doing. Evidence that is being used and that is benefiting the patients, especially those who need it most. And the latter part of what I said linked to equity, right? Doing research that is equitable. Meaning that you are providing the benefits of that research to the majority of people, but particularly people who need it more than anybody else. So already being a pediatrician, you know, children are already left out of a lot of research initiatives or benefits of new evidence. Usually we do adult research first and then, maybe children or sometimes pregnant women might come before that. But then we have children who are experiencing these illnesses sometimes to a greater degree than adults. So we are obviously having to weigh, you know, children's relative fragility, in terms of being research participants and the ethics and all that. But at the same time, I wanted to make sure that children were being included. And so doing implementation science, closing the 'know-do gap' and making sure that evidence was going to benefit people at the population level really speaks to equity for me. And I found it to be well-aligned with my goal of improving the health of children in African countries, but particularly Western and Central and West Africa. So I remember I had a conversation with Chandi, my mentor, because I recall he was doing translational research, bench to bedside. And at the time that I finished my fellowship, I had a conversation with him and said, I can do this bench work, this translational research work. I can write papers. I can do all of this. I enjoy working with you, but I don't think this is my path. We had a very frank discussion and he being the great mentor that he is said to me, "I cannot mentor you on a path that I have not taken. So If you don't think you want to continue in translational research in malaria immunology, whatnot, then that is fine. I let you go with my blessing." Figure out what you want to do or if you ever come back to research and what type of research you want to do. At that time, I had not heard of implementation science. It was going to Nigeria and doing public health that I discovered what implementation science was and how I could improve health on a population level. And I was like, this is what I want to do. And I've pursued it.

[00:17:33] Rob Murphy, MD: Another area that you've touched on in your work is about decolonization in the field of global health. This is a pretty highly-charged word. A lot of people talking about it now. Can you explain this effort and what you want folks here in Global North to understand about this whole concept?

[00:17:52] Nadia Sam-Agudu, MD: Yes, absolutely. Let me take a second to actually define how look at decolonization. It's vast and wide, but people have to realize that it doesn't only apply to global health as in, you know, studying or curricula. And these are really looking at how do we dismantle, redo, upheave, rehabilitate the systems that really uphold white supremacy in terms of knowledge creation, knowledge production, knowledge valuation? And how do we make sure that people of different backgrounds and from different places and the knowledge they have and their skills, expertise are valued and used? And that the place where we have either ignored or ostracized or dismissed, in all of these different places, are restored in a way that is equitable and in a way that provides justice, especially people who have been oppressed, whether historically or currently. And to ensure that these things are not repeated and are minimized moving forward. And so those were some of the points we raised in that editorial, but particularly calling out the Global South and our own roles in colonial behaviors. Not only to fixate on the global North, but to really turn the lens on ourselves and look and make sure that we are not perpetuating these actions as well. When I got to college at the University of Virginia, I learned that college in the U.S. was a bit different. You could really have a wide range of topics as your major and still go to med school. You know, growing up in Ghana, you are put in more of a rigid pipeline. If you're going to be a medical doctor, then you focus on science from high school and you don't stray from it until you get to med school. But then I realized that I had the freedom to do something else and still get my core sciences done. So long story short, I decided to pursue a major in African studies. And so it was a mixture of African and African American studies, because at that time, UVA actually did not have an African Studies major. They had an African American Studies major. So I mixed courses from both areas. And that is where I really, really learned about some aspects of pre-colonial Africa, colonial Africa, and so called post-colonial Africa, and the movements that contributed to what we call flag independence. Because in a lot of ways, the independence is not truly independent. Some of these African countries are still economically and politically dependent. And so, it was great for me to study because I knew I also as a medical doctor wanted to dedicate a significant part of my career to African children. So I felt that studying African history, politics, violence, social theories, anthropology, archaeology, would help me understand. And at that time I didn't know I was describing medical anthropology and some other aspects. I didn't know what it was. I just thought it made sense. And so I never thought I'd really use it beyond sort of my own personal career choices and how I navigated working in African countries as a doctor. But then I revived that knowledge as someone working in global health and focusing on implementation science and equity and realized that a lot of the things I learned in college, I can translate into my work today. Which I never thought I'd be applying, you know, what I learned about colonialism and whatnot. So I actually learned more on top of that. I learned from people who were true decolonial scholars. I read some books. I read them while I was in college as part of my assignments. But others I've also read as a physician who is interested in learning more about decolonization and applying it to my work. And so I've only just started writing about them. So you might be referring to the BMJ Global Health editorial I wrote with my colleague, Professor Sharma from India. But honestly we should learn to not be afraid to talk about things that pertain to the health of people. And I think for people who are medical students and work in other aspects of health, whether it's medical or other aspects, you know, medical students and doctors are not the only healthcare workers, that human health is simple, but complex as well. And it's governed by a lot of social aspects, is governed by political aspects, is governed by religious aspects. And the sooner we realize that, I think the better we will be in doing our work. So I write about this decolonization, but more importantly, I apply that to praxis, as in practical action, in terms of my principles in how I design research studies, my principles in how I comport myself as a researcher, my principles as an associate dean for DEI for med students, and how I do my research and recruit patients and write about these things. And so, my goal is to make sure that I'm consistent with these principles, not only in writing, but in action. And I'm teaching that and I'm infusing that into the research leadership and research training and mentorship that I provide in Ghana, Nigeria, and other West Central Africa countries, and to American students as well that I mentor.

[00:22:48] Rob Murphy, MD: That was a great answer, and I really appreciate you describing the whole process, how you got into it. My final question, I ask every guest that comes on this podcast the same thing. Everybody has a different answer. And it's really, what advice do you have for young people listening who are just now embarking on a career in global health?

[00:23:10] Nadia Sam-Agudu, MD: Aim to be fearless. Be fearless. And that pertains to many things, whether you are in college trying to think of a major and you think something might be too difficult, or you think it's not for you because your family is not filled with doctors, or that you can't afford to go to med school, have confidence in yourself that you can do this. So be fearless there. Because it's really in that space that you can get to do the right thing. Even with trepidation, you can do the right thing.

[00:23:38] Rob Murphy, MD: Nadia, I can't thank you enough for joining me here today. I'm sure everyone is going to feel exactly the same. I'm so impressed with what you've done. and I think your story is remarkable and I think will be very helpful for people thinking of global health as a career. So thank you.

[00:23:56] Nadia Sam-Agudu, MD: Thank you so much, and I'm really happy to have been able to chat with you, finally.

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