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

What is MCH EPI?

SARAH SANTANA:  Hi!  I very rarely find myself being the conservative and traditional speaker in anything or having the conservative and traditional position about anything, but it seems that is what I am going to do here.  I am a traditionally trained epidemiologist.  I have been an epidemiologist since I was 13 years old and read Eleven Blue Men and said that is what I am going to do.  I went through degrees in political science, mathematics, and eventually I went to epidemiology.  Part of the reason I love EPI, is that EPI includes anthropology, sociology, economics, and politics.  You cannot do EPI without being a cartographer for crying out loud, so that it is a discipline that includes many things.  The one thing in my view EPI does not include is a lot of administrative gobbledygook and this is what I call it, not that I do not do it, I have to do it, that is the reality, but that is not what in my view an epidemiologist does. 

If the outcome is a health outcome, it is epidemiology.  If the outcome is something else like the number of widgets, it is not EPI.  It is program evaluation, it is process evaluation, it is keeping track of business, it is whatever you want to call it, but it is not EPI.  An MCH epidemiologist that is evaluating a program where the outcome of that evaluation is infant mortality or a low birth rate.  What we are doing is really a clinical trial.  It is a community version of a clinical trial.  Does this program result in a better health outcome than this program?  Whether it is preventive or it is curative.  If the outcome is going to be how many times did the woman go to prenatal care and does giving her an incentive increase that I think that is a different kind of evaluation.  It does not mean that an EPI cannot help with that, does not mean that the skills that you need are not shared like we have said before.  But think about it, we all learn to read, write, and do arithmetic.  But just because we write, we are not writers, just because we do math, we are not mathematicians, but we all use those same skills in the same way and I have, of course, I have not even began my presentation because I got too excited about all this. So what is it that I‘m supposed to press?  

Oh this. Right, all right, great! One other thing, MCH EPI to me is applied EPI in the same exact way that infectious disease EPI is not disease control, but when we do disease control we use the skills of EPI, we apply them to a real situation and we have a function in public health that is infectious disease control that uses a part of an infectious disease EPI.  However, I do not go around pounding how many people the nurses can immunize in 10 minutes, that is the nurse’s problem. 

That is part of the efficiency issue of the program.  I would like to measure efficacy, not efficiency.  Efficiency is the MBA maven’s business.  I want exposure, whether it is a program or an intervention or a risk factor, and I want a health outcome.  And within that context loosely defined I can see EPI being part of MCH in the same way that EPI is part of anything else whether it is cancer, heart disease, or, you know, or anything else.

Okay, I am an epidemiologist, trained in appendices what I already told you.  Why are we now asking this question?  I think in part because now there are programmatic funding and legal requirements to document the use of data, not because it was not happening before and that is something that I would like to get, whether it is the IOM, the IOM report did not invent EPI as the core function of public health.  It just put it down, codified it, put it in a place where assessment is a core function and we can now quote a scholarly place where it is, you know, spelled out and we can leverage that for our arguments, but it does not mean it was not happening before.  I already said the definition is an another content to me, EPI is the study of the determinants and the distribution of health and disease, period!  To me that is so big that it encompasses almost everything that you can think, but that implicitness is the purpose of EPI. 

Ultimately, the purpose of EPI is the development of interventions, whether they are curative or preventive to improve the health of the population, whether you define thy health by longevity or by quality of life or by both.  I do not know if some of you might remember an argument of Rothman, Greenland, and everybody else a long time ago about whether we were hired guns and that is all.   And we were methodologic people who should present their findings and not worry about how they were used or how our findings were used in implementation.  I think in implicit in epidemiology is, the purposes for this to be used and to be used in implementation, but it does not mean that it is an EPI, who is going to implement those findings because frankly, we do not know enough about implementation to do it.  That is program people, who have a whole other different mindset.  Thank god because we would be abysmal failures at it.  Historically, it is to me is that there were a lot of MCH EPI functions going on prior to the 70s.  The children’s bureau was mentioned before, other local jurisdictions like Ohio, New York City were carrying on MCH EPI internationally.  Since the 30s and the 40s, there has been this exact discipline in the sense of assessment, policy development, changing of programs, looking at how programs affected health outcomes in Latin America, in South Africa, in Israel, and in the European countries.  We sometimes have blinders and do not look either in things that are published in other languages or things that happen in other countries.  And in some cases they have been way ahead of us in getting these types of disciplines developed.  As I said I do not think MCH EPI is its own kind of animal, it is very similar to other types of applied EPI. 

I already talked about this.  Too many administrative and programmatic functions are being rolled into the functions of an EPI.  If the outcome I said is not a health condition, then it is not EPI.  Let us find another word.  From the definitions that I have seen here today, you need superwoman or superman to be able to do this, who has the time, the natural inclination, the love for discipline that goes all the way from a cost benefit analysis, you know, to research on the risk factors and the etiology of a disease.  I am sorry, if you find somebody like that, I would like to meet them.  Evaluating program effectiveness is an efficacy.  I already said all this, I am not going to repeat it.  Research is perfectly appropriate in the context of MCH programs, but it is applied research.  We do not do research in Maricopa County on whether a topical anesthetic or a needleless injector work, we do research on whether they work in a mass immunization clinic, which is a different thing.  So you need to shape your research to the application of the real life program that you are in.

What do EPIs do and do not do in Maricopa County?  They participate in dissemination of their findings, they participate in the policy information, using their findings, they explain data collection, quality of data, data analysis to the program people.  What they do not do is do cost benefit analysis.  What they do not do is process evaluation, however, they also do some things that have not been mentioned here.  They incorporate issues related to infectious disease, bioterrorism and other areas into MCH analysis that people who are only looking at the narrow program piece of MCH may not be doing.  So next year we might examine the effect of influenza on deliveries, which hopefully we will not have to do, but we might, or from our epizoology surveillance we may look at clusters of disease in pets and people in the same family, children and pets. 

Competencies I already said it, there is a broad amount of competencies, but the narrower ones that look into administrative and financial issues are not part of what at least I consider EPI.  Is it the same, is it different from, no it is not different in my view from perinatal, pediatric, or reproductive, it is a subset or companion to it as applied and that is it.  Thank you.