In the tenements of Pakistan’s largest city, Tazeen Hasan Jafar, then a medical student, saw people die from heart attacks, strokes and kidney failure, and children waste away from diarrhoea. Witnessing these preventable deaths claim countless would determine the course of her career.
“The extreme disparity between the slums where people had no or little access to care and this ivory tower of a tertiary care centre where you could get any treatment—I knew then that I wanted to come back and change all of this,” recalled Jafar who was a medical student at the Aga Khan University at the time. “I didn’t know quite how back then, but I had this desire.”
“She is most passionate about bettering humanity and maximising societal benefit,” expanded Sarah.
Education and community work
While the exposure to real-life community health sciences during her medical training was a turning point in her career, the spark of that passion is rooted in Jafar’s childhood.
Jafar, along with her three siblings, grew up in a physically and emotionally close family, surrounded by cousins, aunts, uncles and grandparents, a wider family that provided rich inspiration for the next generation, including an aunt who ran a homeless shelter and another one who was a practising paediatrician.
And while it may have been her grandfather who believed her future lay in medicine, it is her father, Hasan Jafar, whom she credits as having had the most lasting influence on her.
“‘Girls don’t belong in the kitchen,’ was his mantra,” Jafar said.
To reinforce the value of education, her father would make a point to reward his children for academic excellence and when Jafar as a fourth grader came home top of her class he bought her a necklace, a memento she has kept to this day.
While her father focused on academic excellence, her mother’s influence sowed the seed for Jafar’s humanitarian passion. The homemaker—a trained Montessori teacher—would rally the family for fund raisers to give back to the wider community.
Defining success, on her terms
While her childhood imbued her with a deep-rooted sense of responsibility to help improve the world around her, Jafar’s time at Aga Khan University where she studied medicine would help to sharpen the focus of her ambition.
The tenacious and academically bright Jafar initially entertained her grandfather’s dream of pursuing neurosurgery, even citing it during her admissions interview. But it was a clinical rotation to nephrology while on her elective in the US that proved to be her true calling.
“I was intrigued by the many acid-base and electrolyte disorders, all that chemistry and the math that’s required for it. I really enjoyed that.”
At the same time, the medical curriculum at Aga Khan had a strong focus on community health sciences, devoting a quarter of it to this topic, including field trips to the slums.
And it was there, where Jafar had her second realisation. She didn’t just want to help individual patients who could afford highly specialised care. She wanted to deliver sweeping changes that have the potential to improve the health and lives of millions of people.
“This kind of outreach could achieve a lot more but to be able to do that I felt I needed to learn more, be more empowered and advance my career,” she said.
So first, she pursued dual-stream residency training in medicine and paediatrics at the University of Texas Health Science Centre in Houston, working shifts in the neonatal as well as the adult intensive care units.
“It was pretty intense, but I loved it,” said Jafar.
While she thrived on the fast-paced and highly demanding work of an intensive care station, delivering the latest state-of-the-art care to her patients, Jafar’s desire for change began to push its way to the fore.
“Something in me was saying that I also needed to learn how to do clinical research,” said Jafar. “I needed to learn about the tools of research.”
After she moved to the Tufts Medical Centre in Boston to pursue her specialist training nephrology—in both paediatric and adult nephrology—she picked up a research fellowship. And enrolled herself in Harvard’s Master’s in Public Health programme.
“I was doing exactly the kind of thing that I just absolutely loved,” recalled Jafar, who sacrificed her clinical paediatric nephrology training to merge her clinical adult nephrology specialisation with formal training and experience in research.
“I reoriented my training to include that public health aspect, combining my interest in nephrology, hypertension and cardiovascular diseases with population sciences that will have a policy impact.”
She had created her niche. She’d empowered herself, learnt more and was ready to drive change.
Making non-communicable disease interventions fly
At the time, however, international health agencies were focused on tackling infections, and improving maternal and child health.
“In Pakistan and most low- and middle- income countries, there was a high blood pressure crisis with one in four people affected and the vast majority undetected and untreated but non-communicable disease research was just not being funded,” said Jafar.
No funding agency had a programme that she could apply to.
Undeterred by the bleak outlook, Jafar checked every door for someone who shared her vision, eventually spotting a slender opportunity at the Wellcome Trust in the UK, calling them from Boston to ask whether they’d be interested.
She got a yes and sent over her proposal for a trial on management of hypertension. Although the Trust liked the proposal, they were sceptical. Here was this young researcher with no track record, no experience of working in Pakistan, no clinical collaborators and she was trying to set up an ambitious community trial without any readily accessible infrastructure.
“The idea is brilliant, but this is not going to fly, they told me,” remembered Jafar. “They told me I won’t survive.”
Seeing the potential of the proposal, they compromised: the Trust would fund a pilot if Jafar could find a UK-based collaborator.
Tapping her network of clinician-scientists, Jafar soon connected with like-minded researchers at Imperial College London, who shared her passion and commitment to address the cardiometabolic disease epidemic that seemed to strike South Asians more prominently than other ethnic groups.
So, with only US$150,000 in funding, Jafar launched the “Stepped Care Blood Pressure Control Project”. Thinking outside the box, Jafar drew on the Aga Khan University’s child and maternal health infrastructure, adapting it to help her reach out to her target community.
“I used the science I learnt to turn clinical trials into rigorous community trials,” she said.
This pilot was the first such project in a low- and middle-income country. It was so successful that in 2003, Jafar and her collaborators were able to expand it into a fully fledged and funded trial, the control of blood pressure and risk attenuation trial, or COBRA in urban Pakistan. This cluster randomised controlled trial tested innovative, low-cost strategies of community-health worker led home health education coupled with training providers in improving blood pressure control over the long term.
“You can’t imagine how rewarding it is, going into the field, talking to patients and making a difference,” Jafar said reflecting on her experience.
A home coming of sorts
As one of the few experts with experience of conducting effective community trials in a non-communicable disease in low- and middle-income countries, Jafar soon became a sought-after expert. She is routinely invited to speak at various high-level scientific and policy fora and has served as a panellist on the UN High-level Meeting for non-communicable diseases in New York. In her advocacy for better cardiometabolic health and prevention of kidney disease, she has recently added an emphasis on improving mental health as poor mental health is intricately linked with these conditions.
“I’ve led impactful science to improve population health in resource-challenged settings,” said Jafar in commenting on her achievements. “It has been hard work and has involved personal sacrifices including encroachment on family time but has been extremely gratifying.”
Her daughter remembers a mother who would always be there for her just as much as for her work. “She achieved a balance so rarely mastered and so exceptional that I fail to see how anyone could ever ask for more,” summed up Sarah, a high school student in Singapore who hopes pick up her mother’s baton in championing human rights and social justice. “Because of the emphasis in my family, particularly from my mother, on projecting your voice, talents and thoughts, I’ve gradually learned to become a confident, extroverted young woman.”
Around the same time as she made her name with the first COBRA study, Jafar’s CV caught the eye of Professor Thomas Coffman, then the director of the Cardiovascular and Metabolic Disorders Programme of a young graduate-entry and research-intensive medical school in Singapore.
“Here was this CV of a very creative and effective clinical researcher who had just finished this high-quality clinical trial in Pakistan that would change practice, and that really impressed me,” said the now Dean of Duke-NUS and fellow nephrologist.
And his immediate reaction was?
“We need to bring her to Duke-NUS, so she can be unleashed in a situation where there’s the resources available,” he recalled.
So, in 2012, Jafar joined Duke-NUS’ Health Services and Systems Research Programme while also taking on a part-time clinical role at the Singapore General Hospital.
For Jafar, the move brought her closer to the communities she’s working with. It also reunited her geographically with her husband, Fahim Jafary, whom she met when they were medical students at Aga Khan University, who had already started work in Singapore as a senior consultant interventional cardiologist at Tan Tock Seng Hospital and their two children.
Making use of her proximity to South Asia, Jafar adapted the original COBRA trial design for use in a rural setting. In 2014, she launched the COBRA-BPS study to cover 30 villages in rural Pakistan, Bangladesh and Sri Lanka. The trial attracted more than S$5 million in funding from the UK-based Medical Research Council and the Wellcome Trust.
It was one of the first to demonstrate that a uniform customisable, community health worker-led multicomponent intervention is an effective, , scalable, and—at less than US$2 per person per year—a potentially affordable solution for controlling blood pressure.
Jafar and her collaborators published the main findings from this landmark trial in the prestigious New England Journal of Medicine in 2020, and are in discussions with policymakers in South Asian countries to scale-up the strategies they had trialled. Simultaneously, Jafar is working on tailoring their interventions for large-scale implementation in many other low- and middle- income countries.
“And for my work in multiple countries in Asia, Singapore was perfect,” said Jafar, who just last year received her second Clinician-Scientist Senior Investigator Award from the National Medical Research Council renewed.
Through Duke-NUS, she was able to team up with colleagues who had complementary expertise in implementation science and data management, and attract PhD students and team members who are equally passionate about the work.
And she quickly made an impact in Singapore too, engaging the polyclinics to improve care for patients with hypertension and those with chronic kidney disease, two major public health challenges in Singapore.
“After we published the paper, Tazeen worked hard on the implementation of the kidney failure equation in the primary care clinics in Singapore, and now it has been implemented across the polyclinics in Singapore,” recounted Dr Yeli Wang, an adjunct senior research fellow with Jafar’s lab who is currently pursuing a second post-doc at Harvard.
“That was my first time working on a clinical project that went from research to clinical practice, which stimulated my interest in clinical medicine,” added the former post-doc who has since applied to medical school and aspires to be like Jafar—“a compassionate physician-scientist who takes care of patients, observes clinical problems and conducts research to improve health at both the individual and population levels”.