By Gloria Onwuneme, medical student, University of Nottingham, UK
Dr. Katherine Semrau, PhD, MPH, is an Associate Epidemiologist at the Division of Global Health Equity at Brigham and Women’s Hospital, Assistant Professor at Harvard Medical School, and the Director of the BetterBirth Program at Ariadne Labs, a joint health innovation center between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health. The BetterBirth Program is focused on improving quality of care in facility-based childbirth using the WHO Safe Childbirth Checklist. This quality improvement program recently completed a large-scale study of the peer-mentoring implementation of the WHO Safe Childbirth Checklist in facility-based deliveries conducted in Uttar Pradesh, India.
Dr. Semrau obtained her Bachelor of Science from The George Washington University (1999), a Master’s in Public Health from The University of Alabama (2001), and a PhD in Epidemiology from Boston University (2009).
She has worked in women’s and maternal epidemiology for the past 15 years. She was previously project coordinator for a large study in Zambia to improve the safety of breastfeeding for women living with HIV and a senior program manager and assistant professor at the Center for Global Health & Development at Boston University.
Dr. Semrau has been published in New England Journal of Medicine, Global Health: Science and Practice, Controlled Clinical Trials and the Journal Acquired Immune Deficiency Syndrome.
When did you first decide to become an epidemiologist? Why?
As a child, I really thought I was going to be a clinician, and I had always been interested in emergency medicine or pediatrics. When I was 21, I traveled to Honduras, right after Hurricane Mitch hit. My Spanish was quite good, and I was helping translate for the clinicians on this 10-day medical mission trip. When I was there, part of the clinic camp was set up to provide deworming pills for children, and I came to realise that without a water system or infrastructure that was being actively repaired, this deworming pill was going to have only a very short-term impact. I became much more interested in community health and public health as a common good, and in how programs could be developed, tested, and implemented in the real world to make effective health change for a community or a population.
My experience in Honduras, and the volunteering I had been doing with HIV patients in West Tennessee where I grew up, led me to become much more interested in epidemiology. I wanted to understand how disease could be measured in populations, and how global change and health improvement could be achieved. I started to explore public health and pursued a Master’s of Public Health, with a focus on epidemiology and international health. The program requires you to be abroad for a minimum of three months. I signed up for a project that was supposed to be a year-long venture setting up a clinical laboratory for an HIV trial in Zambia on the prevention of mother-to-child transmission. I wound up staying for nearly four [years] to work on it, and looked at the role of breastfeeding in transmission of HIV. This was before antiretroviral therapy was widely used. I learned so much in my years there; I became passionate about development and testing of interventions that could impact women and newborns’ lives. That’s what got me started first in public health and clinical trials, and then in the implementation of different interventions.
How/why did you choose your undergraduate program?
I grew up in west Tennessee, specifically in Jackson, which was quite rural at the time. When I was in high school, I really wanted to try urban living, so I went to George Washington University for the undergraduate program. At this point, I was still planning to become a physician, so I took biology and other premed courses, and I completed a minor in applied ethics. I chose George Washington because I thought it was a nice combination of an urban setting and a school with good academic credentials. Obviously, it was also in the political hub, the capital of the United States.
When I was living in Washington DC, I volunteered with the food bank at the Whitman Walker Clinic, which is one of the HIV clinics that provides resources and care for people in the city living with HIV. It gave me a lot of insight into the complexity and social forces at play around health, healthcare access issues, sociodemographics, and how communities come together.
Choosing your postgraduate universities?
When I was finishing up my undergraduate, I went to Honduras, as mentioned before, and really just decided that I wanted to pursue a career in public health. After this, I was looking for an MPH program that would have a combination of epidemiology, data science, and rigorous skill-set training. My chosen university—University of Alabama, Birmingham—was close to family, which was important. I was also very interested in international health at the time and wanted a program that supported international experience. At the University of Alabama, Birmingham, you had to go work in a context that was unlike the context in which you were raised in order to have a concentration in international health. Over time, this has actually changed quite a bit in many of the masters programs in the United States. My PhD at Boston University was also a combination of fieldwork and being in school full-time.
What surprised you the most about your studies?
In the classroom, you learn that measuring something as concrete as mortality should be relatively straightforward. In order to calculate a risk ratio, you simply have the outcome ratio for people exposed to an intervention divided by the outcome ratio for people in the unexposed population, and then you get this magic number. What surprised me was the reality on the ground: it is hard to collect primary data. Much harder than I was ever taught in the classroom. How you interview people or collect information on the outcome of death is not always as straightforward as asking, “Is the person alive or dead?” I think the complexity around data management and analysis surprised me a bit. It seemed like it should be so straightforward, but practical realities make it different and challenging at times.
Why did you decide to specialize in women’s health?
I started volunteering at 16 in an era before antiretroviral therapy was widely available in many parts of the United States and around the world. I had started to see the discrepancies in women and men’s access to HIV care, but it became even more apparent to me in my master’s degree program.
In my work in HIV, I had become really interested in the risk of transmission through breastfeeding from mothers to newborns, so that was where my work really started to focus on women and children. Women may be socially disenfranchised in different contexts, which affects the access to care they have and the quality of the care that they should expect and demand. Health is also not simply a lack of disease, but a state of overall wellbeing. I became much more interested in understanding how we actually make interventions that work for women. In particular: how do you make those interventions scalable across a variety of settings? Any given intervention might work in one clinic or single community, but can we make it effective across whole countries and diverse populations? How do we measure that impact? That is the perspective of epidemiology. The work I’d done on transmission then began to broaden in scope to look at how we actually prevent neonatal mortality. With BetterBirth, we focused on how to improve the quality of care and facility-based delivery for women and their newborns in families around the world. My lens has been focused on women and newborns for some time now. But the interventions and the content areas have changed over time.
If you had it to do all over again, would you still specialize in women’s health? Why or why not?
Great question. I’ve really enjoyed the work I’ve been doing in maternal and newborn health. I do wish I had more training in anthropological methods, like collecting ethnographic data, in order to really understand the context around health problems. I think such methods might be useful for seeing how people engage with and experience healthcare systems, and I’d advise anyone interested in public health to study these methods.
Has being in women’s health met your expectations? Why?
I think my expectation around women’s health was that everyone in the world could clearly understand the seriousness of the problem of maternal and neonatal morbidity and mortality. It’s a global challenge which the world has been grappling with for quite some time, and there is still so much more to do. What has surprised me is that it’s not always clear to people that maternal health still this significant unsolved challenge everywhere from the US to lower and middle income countries.
What do you find more rewarding about being in women’s health? Explain.
I’ve truly enjoyed working in this field or content area. There’s been a great advancement in global maternal mortality rates: since 1990, they’ve decreased by 44% which is amazing. Yet, there’s still a ways to go. Annually, we still have 300,000 women around the world that die around the time of labour and delivery. Championing the successes is really important, as is an awareness of the fact that we still have more to do. What is most rewarding to me is being part of developing, testing, and scaling solutions and knowing that our work is making a difference for women and babies.
What do you like least about being in women’s health? Explain.
One of the areas that public health and medicine really need to focus on is communication about what the important health issues of our time are, and about the findings from research. How do we make the information straightforward and digestible for various audiences?
I think communication is critical in any field of science. Women’s health at large has a larger, more global voice now. There are campaigns and movements that are focussed on empowering women to come forward. That’s changed over the course of my 15-16 year career, which is exciting to see. Even right now in the US, we are really grappling with sexual assault and the treatment of women. The #MeToo campaign was actually started by a woman ten years ago, but its message is now being acknowledged as a serious issue. So I really feel quite strongly that when these moments arise, it’s really important to communicate with the world about what can be done to intervene on behalf of women’s health and empowerment. It’s important to make sure that the issue is actually being addressed.
Tell me more about how you got involved in Ariadne.
I’d been an assistant professor at Boston University for 4.5 years in the School of Public Health and had just finished being a co-principal investigator of the ZAMCAT study, the Zambia Chlorhexidine Application Trial. That study was following 40,000 mother-infant pairs across a certain province in Zambia. As the trial was coming to a close, the work here at Ariadne was focused on a trial called BetterBirth, another large-scale cluster randomized-controlled. In that study, they needed to enroll 160,000 mother-newborn pairs across the state. My combination of experience in running and developing large-scale clinical trials, in designing surveys, and in implementation had been noticed by funding partners for the chlorhexidine work. Hence, I was recommended to Dr. Atul Gawande as somebody to come in and lead the BetterBirth trial and the checklist program. I then went through an interview process and joined the team here in July 2014, and I’m really proud of the great work we did on that trial.
What’s your typical work-week like?
As a program director and principal research investigator, my role is to focus on the scientific and technical direction of the work we are doing here at Ariadne. BetterBirth is about trying to improve the quality of care for women and newborns during facility-based labor and delivery. My typical work week is a combination of science and writing: working on data analysis, interpreting of data, writing up results, and working on peer-reviewed publications. I’m also working on communication strategies to figure out how to share our results of different projects with governments, researchers, program implementers, and other communities that are trying to improve the quality of care.
Another part of my work week is focused on grant writing and fundraising. Anybody who’s in academic medicine will appreciate that this piece crucial for the work to continue—that revolves around the development of the next research question, and around finding available grants. Another part of my week is really focused on incorporating our findings into the WHO Safe Childbirth checklist. There is the management and administrative aspects of that work. I have a team that I work with very closely here at Ariadne. We are what is called a matrix organization, so there’s a science and technology platform, and a program management platform. I work closely with members of that team and lead the scientific direction for the work we’re doing. This involves management and administration work and a lot of email. It also involves focusing externally as well.
What do you find most rewarding about being at Ariadne?
When we learn something new from an intervention that we try or test, and that changes programs or policy on the ground that truly affects women and men and families’ lives every day. That’s the reward.
What do you find most challenging about being at Ariadne?
Highly rigorous research takes time, planning, and careful management. The Bill and Melinda Gates Foundation has the phrase “impatient optimist.” It alludes to being on the tightrope of between being impatient, yet rigorous. I’m an impatient optimist. I want solutions now for women and babies. But we have to make sure what we are doing really works and is feasible on the ground. Back to that communication piece: I think it’s really critical that scientists and researchers and public health professionals find ways to communicate with the world at large about interventions and solutions that make a difference, and where we have less information, and where we don’t know how to make change yet.
On average: How many hours a week do you work? How many weeks of vacation do you take?
My typical workday is about 9 to 5, or 9 to 6. When we were running the trial itself in India, I had many early morning phone calls at 6:30 or 7:00 AM because of the 9.5-hour time difference. I would make phone calls from home, then head into the office for the typical day here at Ariadne. I work hard not to work on weekends, and really do focus on trying to create that work-life balance we’re all striving to achieve.
The nice thing is that here at Ariadne, we have the flexibility to telecommute if need be. I have an annual 4 weeks of vacation time. One of the things my husband and I enjoy very much is international travel, so we work hard to take the time to travel together and shut off from work.
How do you balance work and life outside of work?
When I am doing my absolute best, I practice yoga or workout at the gym, but I find that harder to do consistently. Luckily, Boston is very much a walking city, so I’m able to walk to and from work. I’ve recently realized that this has been very helpful to my mental health, my energy levels, and my work-life balance. If I took the train, it would be almost an hour anyway, so I figure I might as well take the time to get some exercise. I find it extremely helpful because it’s a chance to listen to podcasts that I really enjoy, and an opportunity to be outside. Boston truly has all four seasons here, so we’re the midst of the transition from fall to winter. Walking is a chance to unwind, and I can talk to friends on the phone while walking. When getting home, walking also gives me the mental break I need from email and work, and allows me to transition into home-mode.
From your perspective, what is the biggest problem in healthcare today?
I think the biggest problem in healthcare is that, while we have dramatically improved access to care in many parts of the world, the quality of care that people are receiving is inadequate. For the past several years, we’ve been so focused on access that we don’t always have great metrics around quality. The challenges are first, how to address the quality gap, and second, how to actually measure it in order to assess whether or not new interventions are narrowing the gap.
Where do you see epidemiology at large in five years?
Epidemiology is going through a very interesting and challenging transition right now. Randomized-controlled trials have been considered to be the gold-standard of testing interventions. However, the real world doesn’t look like a laboratory in which you can control all the other exposures. Humans have free will, which is a great thing! But it also means that complex interactions are taking place. I think epidemiology is having an exciting moment focusing on what adaptive trial designs need to look like. What are the designs that can be used to try to understand complex interventions? We’re focusing on expanding implementation science as a field. Epidemiology is also dealing with big data. Look at businesses like Amazon and Google which use big data all the time to make decisions. Medicine and public health are playing catch-up when it comes to being able to learn and utilize these kinds of enormous data sets that exist around the world. How can we use that information? How do you analyze that data? What do you do with that information going forward?
It’s a challenging time for epidemiology, too, because new advancements may challenge the norms. But it’s a good thing; it spurs growth.
Where do you see women’s health in five years?
It will continue to be a focus. If you look at the WHO Sustainable Development Goals, number three is health and some of its sub-goals focus on women’s and maternal health. There is recognition now that maternal and newborn health, however, is not just about mortality. It’s about wellbeing, too. Again, one of the challenges will be keeping these issues in the spotlight, and being clear about which interventions make a difference, and which ones don’t.
What is your final piece of advice for students interested in pursuing a career in women’s health policy?
As you are in school, make sure you get concrete skills that are focused on data capture, management, analysis, and interpretation. As you can see from my career, my content area has shifted a little bit. You can teach yourself a different content area, and get expert advice on said area, but developing a new hard skill is difficult to do outside of the classroom. Ask yourself which skills you can learn and pick up while you have access to the classroom, teachers, mentors, and proctors that can give you guidance.
Volunteering is also key: it’s what defined and refined my interests while I was studying. My experiences in my undergraduate and graduate courses opened my eyes to public health, and volunteering at a hospital showed me that emergency medicine wasn’t necessarily what I wanted to do.
Surrounding yourself with people who don’t always think exactly like you. Being challenged by ideas and learning from others’ perspectives are really critical experiences. It’s very easy to get into the bubble of school and your own network and your peers that look and talk and think like you do. That’s where the combination of volunteering, learning new skills, getting out there and getting challenged on your ideas is really critical.
About the Author
Gloria Onwuneme is a Danish-born Nigerian who’s studying medicine at the University of Nottingham, UK. She has a strong interest in neurology and psychiatry, and a growing interest in healthcare innovation and medical entrepreneurship. In her spare time, she reads a lot, jogs sometimes, and she (thinks she can) write poems.