Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003
BILL SAPPENFIELD: The first question I want to raise to our panel, do we need a definition of MCH EPI. You could see there is a lot of energy, passion, diversion, directions, a lot of different ways to look at it. Do we need a definition and from whose perspective or what perspective should this definition be developed? You cannot all speak at once.
UNIDENTIFIED SPEAKER: Yes, we do need a definition and I think it needs to come from across that broad team that has been described today. The speakers all talked across the issue of teams that not anyone person that is on that team has all of those skills that have been listed. Systems was one of the themes that I think came across in everything that was said and how those systems have to work together, it is a slow process. So we do need to have a definition and I think we have done some beginning towards that. I think Debbie Klein Walker’s recommendation to have team come together later is very good one.
UNIDENTIFIED SPEAKER: I look at it from a very practical perspective, I mean, if I am hiring somebody and they are an MCH epidemiologist, I would really like to know what they are bringing to the table and what skills they are bring to the team. So, you know, from where I am sitting, it is really that titles do need to stand for a certain level of competency. You need to know that a person is coming to do the job and what that job is. And it is helpful and practical for us to be able to expect that an MCH epidemiologist is bringing a certain set of skills. So I would like to see there would be some resolution because I think it goes back to the issue of what kind of training people are coming to a job with. And what kind of standards you hold them accountable for when they are working with you and when they are working with your projects. It also helps you figure out who else you do need to complement the work you are trying to get done at either a local level or a state level.
UNIDENTIFIED SPEAKER: Yes. From the perspective of somebody, who is working to develop a training program and by the way it is described on the back of the CityMatCH and the Rollins School of Public Health, little purple handout today. The field absolutely does need a working definition, but I think it is essential that some recognized priorities in skills and competencies be established. In other words, what would should the training program provide that other, say undergraduate programs, and other programs do not particularly concentrate on. So that several people have mentioned some of the essential areas including epidemiology biostatistics, data methods and skills. And then I would add advocacy or the process of being able to report and translate findings and be able to exercise some judgment about, you know, where the needs are and how it translate that into action although it should not be the primary emphasis of the MCH epidemiologist.
BILL SAPPENFIELD: You’re assigned to Hawaii as an epidemiologist, not as a team, what are your thoughts?
UNIDENTIFIED SPEAKER: I would echo Barbara’s sentiment. From the state’s perspective it is really important to know, to be able to define what an MCH epidemiologist is, you know, why we are creating a position for a state level, I am a CDC assignee. But we are creating a position for a state level MCH epidemiologist. And we are going to have it explained to personnel how that person is different from a statistician. Because we have a lot of research statisticians and whenever we brought these job description to personnel, they said, well let a statistician do that because does an epidemiologist do counts in and correct rates in and how is that different from statistics, and why it is important.
GARLAND LAND: One of the areas that I have been deeply involved in the last two years is health informatics and as I have listened to this even though I saw some words relating to health informatics in some of the presentations. I must admit that all the work that I have been involved in and still going on nationally in terms of integrated child health systems. I do not find any very many “MCH epidemiologists” involved in those activities. I see IT people, I see MCH program people. But I do not really see the typical MCH epidemiologist. And so if you do not define it then as this whole area is moving on, we used to think the important thing was data linkage. But I really think the future now is something completely different and not including a broad prospective of what all the skill sets are to make things happen that I think we are losing out.
MICHAEL KOGAN: Well, I do think we need a definition. Looking at the definitions that have broached today, I think we are very close. However, I want to emphasis that I think the definition should focus on the vision of what an MCH epidemiologist is, as well as the competencies needed and not the actual job duties of what goes on. When you do that you diffuse the definition unnecessarily, for example, if one took the job description of a lawyer and broke it down by their actual job duties, would it be a lawyer/accountant, lawyer/advocate, lawyer/biller, whatever. You are still looking at the vision of what a lawyer is, and I think that is what we need for this field.
BILL SAPPENFIELD: So, we have talked about from a perspective, I hear most of you talking about that it is not necessary that one individual, but a team in a mix and we have talked about. We really need to have one in case if we do not, it makes it very hard, and listening to Garland, we maybe missing out on some very important future things that are being defined in semi-concrete, not concrete anymore. The question from there is, lets go from the easiest prospective. Sometimes it is easier to talk about what something is not. What is not, MCH EPI or what is MCH not? Let, for example, what your, Sarah Santana’s comments are? You know, it is not the administrative gobbledygook, did I say that correctly sir? It is, and she actually said it is not program evaluation, if it does not have a health outcome, it is not MCH EPI. There are lots of “nots” in there, what are your thoughts about, what it is not, are we talking about a small MCH EPI or a big MCH EPI?
UNIDENTIFIED SPEAKER: I’ll just make a very short comment. I think it is important to know what it is less of and what it is more of, as oppose to what it is absolutely not. I am not sure that the people that I have met who call themselves MCH epidemiologists, or who discover that they are MCH epidemiologists, would probably be fairly reluctant to be absolutely exclusionary. So, I would say, let’s, maybe, talk in terms of more and less.
BILL SAPPENFIELD: Very nice point. I can’t polarize the discussion this easily, but it is much easier to talk about more or less. However, my family can talk about more, not less.
UNIDENTIFIED SPEAKER: You know, I think, again, from a practical perspective, it is usually somebody, who does, is grounded in the study of epidemiology for us. We do want somebody who has competencies of an epidemiologist and that in fact is a very unique set of skills. Some of the other skills that we have talked about are not as quite as unique. You know, program management skills, maternal and child health content area skills, analysis skills, and evaluation skills are only the part of the team of folks, who work around the issue of improving the health status of families. But we do need the core skills of an epidemiologist to best define the work that needs to get done and to bring to the table something nobody else is going to have. So I would push that that be defined very well, so that there is a lot of success in getting people trained very well on those sets of skills, and then like with any other competency that people develop, they have their other interests and their other areas where they are inclined to get more or less involved; and that that too then makes a good fit on your team. But these core set of skills that I think they absolutely have to be competent and then they have to bring to the table, because nobody else is going to have the epidemiologist’s training at the table.
BILL SAPPENFIELD: I think that was very interesting that you choose EPI as the core, not MCH as the core, but you talked about EPI as a core. Other thoughts, is that is their a core, which we build around? Is there a single list?
UNIDENTIFIED SPEAKER: Bill, can I just qualify, for second, I mean the reason I say that is because there are lot of people who come out of masters in public health programs with a basic MCH background. But they do not have real skill in epidemiology, and that for me is a tension. I mean, if they are coming and they are saying they are an MCH expert and I am now saying okay, will that mean you are grounded in epidemiology as well, and then we start doing some work, and they do not have the epidemiology skills. It is not that helpful.
UNIDENTIFIED SPEAKER: What is an MCH epidemiologist less of? When you say not, initially what I thought was not cancer as I do not know anything about cancer at all, but MCH epidemiology is now encompassing women’s health, so I guess what? I need to know something about cancer.
UNIDENTIFIED SPEAKER: When I think about some of the really effective MCH epidemiologists that I have worked with, there are people that have people skills and they listen to families; they listen to colleagues. And they are able to translate very complex thoughts and all of these technical skills I think are very important. But I think that beyond those kinds of competencies, there is a bigger set of leadership competencies if it would be going to be able to make a difference, translate into actual implemented actions, and change for the future that families will embrace. Because they have to embrace this as much as practitioners in the field, so, I think that yes we have to have a core set of technical kinds of skills. But beyond that there are other competencies for working with people in their emotional intelligence piece that we haven’t paid attention to yet.
MICHAEL KOGAN: Well, in order to prepare people for the presidential debates next year where they get to ask the question, and answers slightly different one. One of the issues that came up among all the speakers is, is MCH epidemiology part of a subset or a part of perinatal or pediatric epidemiology or is it same thing. I think, our first three speakers said “No”, Sarah said “Yes”. I am a classically trained epidemiologist and I agree with Barbara that to be an MCH epidemiologist, you do need a core set of competencies, otherwise you are lost in the job. And I want to answer whether I think it is a part of perinatal and pediatric epidemiology. I think if one would draw a Venn Diagram, I think there will be a big overlap between the two, but they are not exactly the same. Let me give an example. Now in the Wall Street Journal, the headline was “How to give your child a longer life?” Can everybody read that? No, okay, I will do it for you and in the interest of time I won’t read the whole article. It maybe hard to believe that the health decisions you make for a five-year-old today will still count when he or she is 50.
That a growing body of evidence shows that childhood is actually the best time to start protecting an aging body, buckling again for a lifetime of good health. Now, they go on to talk about numerous studies. All those studies were done at universities that I define as pediatric and perinatal EPI in the classic sense. However, on that same continuum, when we have the research and you are working at state or local health departments, who there is going to evaluate the research? Just see how applicable it is. Who’s going to help translate it for people in the department? Who’s going to monitor the prevalence in state and local areas? Who’s going to evaluate the effectiveness of any programs as far as health outcomes, it is the MCH epidemiologist and that is why you need classic EPI skills to do that.
GARLAND LAND: One of the points that was made that basically comes down, is it really useful or not? Let me just relate a story that happened over ten years ago. We had a, our present attorney general was our governor for eight years, very conservative at time period in Missouri. We then had a democrat governor, who was a moderate-to-liberal that was elected right after him. _______and I was invited to go to attend a meeting of his transition team that related to health and as the team members were being introduced, I realized that three out of eight people were from plain parenthood. Now, during John Ashcroft’s administration, we could not use family and planning in the same sentence. So, I kind of got the sense that the times were a changing. And so I went back to my staff and I said, “we need to start working on some analysis on unintended pregnancies”. I got a feeling that there can be a need for that in the future. So they worked up a very good article, and sure enough of about a few weeks later, I got a call from the budget office in the capital saying, “Do you have any data on unintended pregnancies and family planning issues?”
I said “Well, yeah when do you need it?” and he said “how about in an hour from now”. I said sure, I would be glad to fax this over to you. And, I don’t know to what actually what happened, was that there was a half-million dollar family planning program established and it would go to a million and a half in the next few years. I am not sure that our report made all that difference. I never wanted to take that claim, but I always wondered what would have happened if I had not attended that meeting and if we had not developed the report and how irrelevant we would have looked. If I would have said, give me three months and we will be glad to give it you, because it was not going to happen then. So, I think it really comes, you know, I look at all the charts that I got on these. And I have made presentations at national museums so forth and I always come back and I say “what difference that it really make”. And I think that is really what it comes down to and we already have we are refining it, what difference it is going to make and that is a bottom line question for me.
BILL SAPPENFIELD: Well I’m going to take advantage of you, since you spoke last. Garland, for years having developing your center, and in earlier discussion that we had, that you had problems getting statisticians and epidemiologists in and you used social scientist to help you feel your positions to get down what were classic biostatistics and EPI jobs done. And we just talked about the need of core of EPI skills. Would you like to add to that discussion?
GARLAND LAND: Well, indeed at the state level I can’t hire MCH epidemiologist and we just hire one recently. First one we had actually held in the state, now our state epidemiologist comes from MCH background. But at least my staff, you know, I do hire people who have a masters degree in psychology or sociology or whatever and then we try to re-gear them, re-think them. Because, you know, the people coming out of schools of public health, you know, they are going to be at least biostatistics programs, they are going into, you know, with HMOs and hospital systems and so forth. So, we have to find people, who are basically very credible and smart individuals and try to retool them into the area of interest for us and that takes a lot of time and sometimes you find good people and they stick with you and sometimes they don’t. We are going through that recycling process. But, yeah, I need people who have basic statistical skills, basic EPI skills, basic data processing skills, basic SAS skills, and analytical skills, people who can write, you know, it is hard time finding people who can write anymore. I do not know where they lost that skill, but they do not have it, they do not put things on paper and logic. And then I think it was you or someplace I read recently, it said, you know, most of the work is after the paper is written is to make that somebody else is using it and typically that is forgotten. We finish the paperwork, we publish it, and it lies on the shelf and finally people who take up the charge and can really relate it then to the real world later on is a real skill that often times you do not find.
BILL SAPPENFIELD: As you earlier said an epidemiologist takes as much time to use the data afterwards as it did for you to write the report and if you are not willing to spend that time afterwards, I am not sure why you wrote the report. That is another talk.
GARLAND LAND: I agree with it.
BILL SAPPENIELD: But you do talk about a core competency. They may not come with them, but you do migrate them towards what those needs are. And so that is I call now, that is a little bit different from what Greg was saying because one of the things that Greg said is he thinks an MCH EPI and MCH are becoming more one or the same, which I also thought was somewhat said by Barbara. When she said when she hires someone, who is an MCH if they do not have EPI that they were not going to be help for an MCH generally. But they need to have some EPI with them, is that what you are saying or am I putting words in your mouth? Make sure we said it correctly.
BARBARA FERRIER: I think I said the opposite. I think there is a very big difference who come out from the broad MCH background. The people, who come out with the MCH EPI background, at least I am not feeling that, I want a person who claims to be an MCH epidemiologist, who really be an epidemiologist with a good understanding of MCH. If I am hiring somebody, who tells me that they have a background of MCH programs, I would not expect that at all to serve the purpose of being an MCH epidemiologist.
BILL SAPPENFIELD: So you see them distinct?
BARBARA FERRIER: I see them as very much distinct.
BILL SAPPENFIELD: Good. I want to go to the last question. The last question is, obviously, we do not have the answer and I think, you think, we do have the answer, you think we are very close. Sarah, would you like to come back up here?
BILL SAPPENFIELD: I just say that, so how do we come to an answer? I am going to leave that with the audience. How do you suggest we come to an answer and how do we move the field forward, and I will allow question from the presenters in a minute.
BARBARA FERRIER: You know, I guess I do not see it as a huge dilemma and maybe I am missing something. It seems to me that everybody who presented spoke about the need if you are doing MCH work to have a team of folks and I actually think there are lots of questions that people were asking, are not questions that can get answered by any one individual anyway. I do not think it is the epidemiologist on a team who answers what difference it is going to make. I think that is a team question and it gets a team answer. And lots of people need to contribute to both the asking of the question and reviewing the answers and what you need is a team of people who actually are able to complement each other and I think the field of MCH is where I think the debate needs to happen right now. What are the competencies that we need to look at that are presented to people who are interested in going into the MCH field and then the people choose where they want to specialize. I think that there is great need for there to be different approaches towards evaluation right now. I think there is a lot of other new emerging issues that need to be paid particular attention to on and I think people need to look at sort of what is field of MCH? And how we are training various people in MCH? And what are we offering along the spectrum? Because I think the MCH epidemiologist, for me it is an epidemiology based set of task and they need to be part of the team however that can look and answer those broader questions. I do not think they are going to answer by themselves Bill.
BILL SAPPENFIELD: So you are going to add to that? Or add another something.
UNIDENTIFIED SPEAKER: I very much agree with what Barbara said. But I think we need to put ourselves to the test. In other words if we come up with the definition it has to be usable and practical and the two principle uses I see for such a definition are really job descriptions and the justification for the need to hire the people in state and local health departments. And then on the other side of the client training programs, equally need that definition to justify putting university resources into expanding programs into recruitment and the people going into it need to know that there is something there for them when they come out. So the definition really has to be practical and usable.
BILL SAPPENFIELD: Do you have one last comment, Gerald? Michael, you go ahead. You can have two comments.
MICHAEL KOGAN: Okay, I thought presenters did a wonderful job, they did speak with great passion. I was struck and all they agreed on in many ways that we are in applied field about the competencies needed. When some of the job skills that were put up, it was noted that only a super person could do them all. I agree with that, we work as part of a team, now present company excluded I do not many super people, who can do that. In terms of where we go, I do think we are very close. Debby has proposed changing the name of this conference to the MCH Information Statistics Research and Evaluation Conference. I think she is close. I would change it to the Maternal Infant Child Health Information Program Research and Evaluation Conference, which then has the acronym MICHIPREC.
BILL SAPPENFIELD: I think you just lost your position on the planning committee.
MICHAEL KOGAN: Thank God.
BILL SAPPENFIELD: Greg, you had a hand up I could not give you opportunity.
GREG ALEXANDER: I have a question for the panelists. I can agree with very narrow definition of MCH EPI, in fact I agree what Barbara was saying, that leads us to this other group of tasks. And I don’t have name for them, maybe the MCH Health Services Research, but are we just certainly talking about splitting off our profession, (no) or are? You weren’t clear about these points, this is going to be endless, as you define MCH epidemiology more narrowly _______what’s left?
BILL SAPPENFIELD: Obviously…
Would you like to share your comment too, Arden?
ARDEN HANDLER: I just want to say that I really agree with Barbara that this is really a team effort and when we actually see the MCH epidemiologist in the states in early and mid 1990s, it was evaluating MCH epidemiologist as part of a team. Our evaluation included the MCH director, MCH program analyst, MCH epidemiologist all together how their effort moved the field forward and I think what we say in our definition whether we keep this one or not. It says for, you know, doing all this stuff for the purpose of implementing effective interventions and promoting policy development. It does not say that the MCH epidemiologist has to do that per se, but they do that together with a team and move forward as a group to make a difference in their state.
BILL SAPPENFIELD: I think we have an incredible amount of agreement and if I seem to be trying to push the edge, because I do think there are some issues that still be somewhat resolved. I must tell you my happiest thought is I am not looking at blank faces and I am not having to justify why anyone would want one or pay for one. I am not looking for somebody, who said I cannot afford to have one anymore. The question is how to move forward with what needs to happen and with that I want to thank our tremendous set of presenters and tremendous set of panelists for the job. Well done and I appreciate it.