Unwavering Commitment

As CEO of the Africa Academy for Public Health in Dar es Salaam, Tanzania, Mary Mwanyika-Sando, MPH ’13, leads a team that is improving population health through research and training

Winter 2019 | by Jan Reiss

Sometimes a new life begins when another life ends. So began Mary Mwanyika-Sando’s life in public health—witnessing the death of a woman in childbirth, when both were 25 years old. The scene was seared in Mwanyika-Sando’s memory, a pivotal experience that shaped her path toward public health.

A newly minted doctor, she was an intern rotating in obstetrics and gynecology at Muhimbili National Hospital—Tanzania’s national referral hospital, which provides the highest level of medical care. “The woman died in my arms in the labor ward,” she says, visibly distressed even years later. “I was the only doctor, because I was on call. I had seen women die before, but I was never responsible. I had never been the first on call.”

The young woman had already given birth—her newborn son had died—and had suffered postpartum hemorrhage. She was brought into the labor ward on a stretcher, lying in a pool of blood. “The midwives and I, we were all rushing to help her,” says Mwanyika-Sando, MPH ’13, “only to realize that she was gasping. Her veins had collapsed, and she was paper-white pale.” After giving birth at a dispensary—a facility that provides the lowest level of care—and suffering the hemorrhage, the woman had been transferred to a district-level health center, where ideally a transfusion would have saved her life. But that facility had no blood. The woman was eventually rushed to Muhimbili Hospital, but the delay had been too long. She bled to death.

“This is a consulting hospital—we should be able to save lives. And she was my age. I thought, this is like me dying here today,” Mwanyika-Sando remembers. “The senior midwife came, telling me, ‘This is hard. But we lost her. We lose so many women. It happens every day. We have to do something about this.’”

After the death, Mwanyika-Sando reviewed the patient’s records and saw that the woman had made five prenatal visits. She had been diagnosed as mildly anemic at her first visit and remained anemic throughout the pregnancy—a risk factor for blood loss at delivery. “How did we miss that?” laments Mwanyika-Sando. “And how could there have been no blood at the district facility? That’s all public health. We keep advocating for women to come for prenatal visits. This woman was very adherent, but she still died. I came to realize that, truly, the health system—we all failed her.”

That painful realization shaped Mwanyika-Sando’s life and career. Now, as CEO of the Africa Academy for Public Health (AAPH), she is working to create health systems that will ensure quality health care for mothers and their newborns—as well as for all people across Tanzania and sub-Saharan Africa.

Death of a classmate

Mwanyika-Sando was in high school—at a special boarding school for high-achieving girls from across Tanzania—when she realized that she could become a doctor. The profession would combine her love of science—especially biology, at which she excelled—with her desire to help people.

When she was around 17, after one of her classmates died, she began to ponder questions that bridged medicine and public health. “I later came to understand that my classmate had died of a septic abortion,” says Mwanyika-Sando. In fact, Mwanyika-Sando believes that two classmates had developed sepsis from botched abortions, but the second young woman survived. It begged the question: Why did one live while the other died? Medical school provided some of the answers. Public health would provide even more.

Although she considered studying in the U.S., she chose to attend Muhimbili University of Health and Allied Sciences in Dar es Salaam, a sprawling city of some 5 million people that hugs the Indian Ocean. “I always knew that I would work in Tanzania,” she says, “so I wanted to understand the situation in this country.” She met her husband, David Sando, SM ’17, SD ’20—a health systems researcher focusing on quality of care—when they were first-year medical students together; they now have two young children.

In medical school, Mwanyika-Sando stood out for her passion and laser focus. Her reputation made its way to the Harvard Chan School and to Wafaie Fawzi, Richard Saltonstall Professor of Population Sciences, professor of nutrition, epidemiology, and global health, and chair of the Department of Global Health and Population. “I first heard of Mary from colleagues and friends who were her mentors in medical school,” he says. “They referred to her as the best student in her class, someone who was interested in learning about research methods. She joined the team for one of my ongoing clinical trials in Tanzania and quickly surpassed all expectations with her diligence, hard work, and high-quality performance.”

Scaling up maternal and child care

In 2005, after completing her medical training, Mwanyika-Sando became manager of maternal and child health at Management and Development for Health (MDH) in Dar es Salaam, an organization that Fawzi had co-founded. When the Harvard Chan School was awarded a $362 million grant from the U.S. President’s Emergency Plan for AIDS Relief in 2004—the largest government grant in Harvard University’s history—the School contracted with MDH to run its HIV/AIDS programs in Tanzania. Mwanyika-Sando was instrumental in scaling up treatment for HIV/AIDS, extending coverage and improving quality of care for pregnant women and children, and enhancing the program focused on prevention of mother-to-child transmission of HIV. According to Fawzi, her work resulted in countless lives saved and better health for many more.

Mwanyika-Sando had planned to become an obstetrician-gynecologist, a consultant, a teacher, and a researcher. But after several years of working on HIV/AIDS, she realized that she wanted to make an even larger impact. With experience in public health research and an understanding of the importance for her country of evidence-based public health policies, she applied to the Harvard Chan School’s MPH program in global health.

At the School, she focused on maternal and child health, working closely with Fawzi and with Ana Langer, professor of the practice of public health and coordinator of the School’s Women and Health Initiative. “She was a star,” says Fawzi. “It seemed everyone knew Mary, and she dedicated herself to advancing her capacity in research.”

Powerful public health leader

After receiving her MPH degree, Mwanyika-Sando returned home and spent a year at UNICEF, serving as the organization’s health-systems-strengthening specialist. Working with different sectors within the Tanzanian Ministry of Health brought lessons in how big government works, how policies are formed, and how donors negotiate with the government.

In 2015, she joined the Harvard-affiliated Africa Academy for Public Health—of which Fawzi is a founding board member—as deputy CEO. She has been CEO since 2017. Established in 2009, the organization represents an evolution of 40 years of research collaborations between the Harvard Chan School and several Tanzanian public health research and training institutions. AAPH’s three-pronged mission involves conducting scientific research on priority public health challenges in sub-Saharan Africa; providing training to increase the number of African public health professionals; and serving as a platform for sharing research across countries and regions. “At AAPH, we know that the translation of research into practice can only happen through the exchange of knowledge among diverse and multidisciplinary groups,” says Mwanyika-Sando.

Some AAPH research projects begin at the Harvard Chan School, which then engages AAPH as a subcontractor on the ground. One such effort focuses on nutrition. “Many women in Tanzania are smallholder farmers,” says Fawzi. “They are also mothers who are interested in their own health and the health of their families. We are working with Mary and AAPH to bring the public health sector and the agriculture sector together to tackle the underlying causes of child undernutrition through the use of specially trained agricultural extension workers and community health workers. They guide local women on best practices for cultivating nutrient-rich crop varieties and provide basic nutrition and public health counseling services.”

AAPH also often takes the lead and develops its own programs—on maternal and child health, mental health, noncommunicable diseases, and infectious diseases, as well as nutrition—and seeks input from Harvard and other institutions in Tanzania and elsewhere. One of AAPH’s current research projects is the Dar es Salaam Urban Cohort Study (DUCS), initiated in 2011 in partnership with the Harvard Chan School and Muhimbili University of Health and Allied Sciences to establish a demographic surveillance system for monitoring health and sociodemographic events over time.

The surveillance site covers a population of approximately 100,000 residents living in some 20,000 households in two low-income neighborhoods in Dar es Salaam. Research assistants visit each household two times per year to collect information on births, deaths, marriages, migration, water supply and sanitation, socioeconomic status, and food insecurity. This urban surveillance site serves as a platform for evaluating the effectiveness of public health programs, training researchers and service providers in communicable and noncommunicable diseases, and tracking disease trends and risk factors, migratory patterns, environmental exposures, and vital events. According to Mwanyika-Sando, the ultimate aim is to “help policymakers in setting health priorities and at the same time allocate resources much more efficiently.”

Fawzi notes that AAPH is increasingly being recognized as one of the leading research organizations in East Africa. Among its many funders are the Bill & Melinda Gates Foundation, the U.S. Centers for Disease Control and Prevention, the National Institutes of Health, and the World Health Organization. The Tanzanian minister of health presided over the official launch of AAPH’s strategic plan in January 2018.

“In addition to public health research,” says Mwanyika-Sando, “one of AAPH’s core goals is to build an African public health workforce.” AAPH offers trainings in collaboration with Muhimbili University, often with Harvard Chan faculty as instructors. Recent participants learned how to apply for grants; manage, monitor, and evaluate programs; and write article manuscripts. AAPH also provides summer internship opportunities for undergraduates from Harvard and other U.S. and non-U.S. institutions.

A wish for every pregnant woman

Mwanyika-Sando’s own childbirth experiences in that same labor ward at Muhimbili Hospital were completely different from that of the young woman who died in her arms. “I had two healthy children and two uncomplicated deliveries,” she says. “It’s not fair that because I am a doctor, because I worked at that hospital and had my own gynecologist and obstetrician, everything went as I had dreamed. Why should other women’s dreams not come true? We need to get to that level where every woman’s pregnancy outcome is truly a celebration.”

That ambition, says Mwanyika-Sando, is achievable “only if we agree that one maternal death is one too many. We need to reduce disparities and inequalities in access to quality health care for all women of reproductive age. This includes ensuring access to contraceptives and comprehensive services. All women’s voices need to be heard—they need to be part and parcel of the provision of women-centered care.”

Langer has great respect for her former student. “Mary’s commitment to the health and well-being of women, children, and families is unwavering,” she says. “Her work is already making a huge difference. As a strong public health professional, powerful advocate, and effective leader, Mary is a role model for hundreds of students, young professionals, and senior colleagues, especially women, in Tanzania and across Africa.”

“Mary sets an example for our students,” adds Karim Manji, MPH ’03, a pediatrician and professor of pediatrics and child health at Muhimbili University of Health and Allied Sciences, who has been a cherished mentor to Mwanyika-Sando since she was his medical student. “Many have gone and done an MPH in the United States of America, but they would then want to stay there. Everybody finds it very lucrative to stay over in America. But there are a few who would come back and give and continue the work here. Mary is one of those few. She is iconic. She is exemplary. We want to clone her.”

Jan Reiss is assistant director of development communications and marketing at the Harvard Chan School.

Photos: Jan Reiss/Harvard Chan School, Craig LaPlante/Harvard Chan School, Planet Earth, Shutterstock