Ninth Annual Maternal and Child Health Epidemiology Conference / December 10-12, 2003

What is MCH EPI?

DEBORAH KLEIN WALKER: This is really a great idea to be doing this, and I guess I am up here for a number of reasons.  I was one of the ones about ten years ago.  First of all, I do not have any degree in Public Health at all.  I come from another field to Public Health, recruited to Public Health, and did learn some skills when I was in the School of Public Health, but actually felt that I knew a lot of what everybody was talking about or they were already doing in MCH EPI.  So I am one of the ones who said to the Bill Sappenfields of the world and others, you know, you have to be an MD to really be an epidemiologist and have all these skills down.  You know, there are other things that add to it.  So, here I am ten years later up here after doing it, but I just want to say a couple of things.  I come from a field, trained as a developmental psychologist in a school of education, worked on many of the large scale programs in the early 70s.  Actually one of my colleagues invented the term “implementation” in the Head Start help start plan variation experiments.  And worked on major interventions and an evaluation of something called the Brookline Early Education Project, which was population based on visiting with systematic developmental screens, so that’s kind of the world I came from in to Public Health now.  Now I realize we are calling these things other things, but I was really doing the stuff as well.  So, I just wanted to say one more perspective on this and I think it is great that we are doing this.

First, I just want to add a little to the past history and I hope we can put of all these together in one kind of Journal article for the MCH Journal, but from the State Title V perspective, which is of course, where I have been the most active in the last 15 years.  I really saw that there were lot of needs for data and really wanted each MCH program in the states to have a data contact and so one of the big pushes was as we actually very much lobbied for that at the same time, just a little piece of history that goes in there.  And then was MCHEP with City MatCH was very active with all of our colleagues and making sure the CDC and HRSA were on the same page and setting up that national action agenda, which happened after one of those meetings with Bill Sappenfield, Stephanie Daniels, Magda Peck, etc.  So, those were just a little of historical tidbits, because I think what we were saying is we all came for this different reasons at the same time and there was not one major player.  It was the synergy.

Okay, in thinking about this, I am fairly thinking about it more as a field of epidemiology.  I talked to a lot of my epidemiologist friends and I looked at a lot of textbooks here, because I am not trained as an epidemiologist, wonder, well, am I missing something?  But I will tell you from the MCH perspective, whether you are at a state level, local level, or Federal, all of us working together to change the system, to improve health of mothers, kids, and families, we need people who have these skills.  So, I am going to list all these skills and you can tell me whether they are part of epidemiology or not.  That will be the answer.  We need needs assessment, health monitoring of populations.  Clearly, that piece about the populations is the unique part about Public Health that I did not learn, by the way, before I came to Public Health.  Health outcome’s research, performance measures, financing and cost benefit studies, we need evaluators, who know both experimental and quasi-experimental designs.  We need data for program planning, policy development, education, and advocacy.  You can see a lot of this stuff people have said before, but I have tried to actually make it as broad with all the buzzwords, all the fields that link to health.  We also need people who know about measurement of behavior and development, and I will just say that is one of the things I still don’t find in any of the text that I look at.  That is the field from which I come, but there is a huge need in Public Health.  Qualitative studies, we need people who understand those as well, not just quantitative, informatics applications, and then finally community-based and  just clinical, but the systems kind of work, the community-based, determinants of disease, health behaviors and outcomes. 

People talked about that, and efficacy and effects of the studies.  You really need persons on a team; you can call this epidemiology if you want, who have these skills to get the work done.  So, I just want to make a couple of other points about where I find epidemiology classically not, it really needing much more embracement of social behavioral, and educational sciences.  There has been some in the last 10 years, but there needs to be a lot more.  Just the term sensitivity and specificity and epidemiology, it drives me crazy that everyone who learns about that never learns that there is a different components to that.  There is error and the measurement errors, and a reliability of validity of measurements and then there are the errors in design from internal and external validity.  I would like someone who is really smart to write an article, put those together, but that is where the social and behavioral sciences, that we learn about in psychology and sociology, could really add a lot to epidemiology, enrich it.

The next big piece is, health is finally realizing that there is something called implementation that you do not just do intervention in a community and assume that it is the same thing.  You really have to study it.  I have to tell your colleagues in education and I put education there, are the ones who actually really first did that over 30 years ago.  So, again, that is something that we do not normally include and we need, and I just want to make some of these analogies, so people would understand what I was talking about when I said what we need to include.  Now, I also, looking at the text the lot of you in here, whom I respect as epidemiologist, have been trained as epidemiologist in the classical way, know that it has changed over time immensely or I would not even be at this meeting up here talking.  I mean that is one of the wonderful things.  It has changed.  It has changed from its invention.  It is changed in the century.  It changes because of the nature of the diseases and the outbreaks, and for instance if you are considering violence as an outbreak, you have to change what is involved in epidemiology, you do not do it in the classical way you did for a communicable disease.  I also look back and there was a guy at Harvard School of Public Health, who wrote on the occasion actually of the 30^th anniversary of the EPI section in APHA that if EPI is to be the diagnostic discipline of Public Health, then it must be concerned with usefulness of the definition of the health problems, determinants of the principles, and evaluation of the accomplishments even back then, talking about that. 

When I look at the classic EPI texts today though, they do not do much to include any of this stuff still.  They might have a chapter on applications and clinical, but it is still that basic strict traditional EPI, which is what happens in a lot of our epidemic settings.  Then, I found a really good applied epidemiology book and I was really impressed of this applied epidemiology book.  Because, may be some of you know about it, Brownson and Petitti, what they talked about and say is that applied epidemiology synthesizes, and applies the results of etiological studies to set priorities for intervention, evaluate public health intervention and policies, measures the quality and outcomes of medical care, and effectively communicates epidemiological findings to health professionals and the public.  So this book talks about it as the tool that you use for policy setting and planning, but it also includes all of these different pieces that I said we need, but have often been left out.  So, I come up with, there is a couple of solutions here, and I think this is a great time to discuss it and what do we want to do.  First, we can either consider MCH EPI as a subfield of traditional EPI and acknowledge that it is going to take a lot of other folks, program evaluators, health science, health services researches, etc., working together with this MCH Epidemiology to do all the work we need to do and to improve that and that is one way to go.  Or, I think this is the way I would prefer, is to really think about epidemiology, and MCH Epidemiology in particular, as a broader set of things that you need to do the job, to use information and data to improve the health of mothers and kids. 

If we are going to do that, I think we should really try to write down what is included and what that means, in a way of saying, it is that applied term.  But if we do that, we got to make sure we are going to do that and all of our other epidemiology colleagues and the whole field of Public Health are going to go along with this or we still going to be struggling with what is this.  If we do this and include everything in MCH EPI or EPI, then we have to say, is it okay for me to say that I am an MCH Epidemiologist?  It is not the way I was trained and some people might be horrified to say that, as opposed to someone had a more classical training.  But I mean I think that is one of the issues, then you are going to have to reserve the name for a number of people who do the kind of work we need to do.  So, hence that is why we are here today discussing this.  In any case, I think we should continue this dialogue.  I think it is extremely healthy and it shows you about the nature of the field, as well as what Public Health needs in terms of the methods and skills and I am sure there are methods and skills we have not even thought about today that we will be including in our definition as we go forward.  I think we may wish to consider changing the name of this conference depending on the outcomes of the what we decide if we decide it is bigger, but I think we should start to clarify from what it is, and then finally a bigger challenge for my friends in the Federal level etc., we need a consensus conference.  

I think about bringing together even the CDC centers on this and I have to tell you the CDC centers are giving these different messages in the states.  Some say you have got an epidemiologist and you need program evaluator.  Others are talking that these both are the same thing.  That is happening right now.  Okay, and even________.  When we have our friends in SAMHSA, which is Public Health Service and they do not even know what EPI is in the whole, but yeah, they need the tools.  No I mean, I have been substance abuse director of the United States, so I say that respectfully.  But they really need to either be brought in and do that.  And then you have HRSA, so I think it is a time for a field to come together and really clarify for really good reasons, what the field of epidemiology includes and I hope it is a broader field with the emphasis on using the information on a population basis.  And then, get on with the work we need to do. Thank you.