MCHB EPI Atlanta Conference
 
December 5 - 7, 2006

MCH Epidemiology: Mapping the Future

VIOLANDA GRIGORESCU: Good afternoon. Thank you for allowing me to share with you a state perspective and I will try to be brief. But I like to raise some other issues or questions in your mind as we have to discuss what MCH Epidemiology actually means. And as I said, I’m going to share a field perspective, which of course is going to be biased by my personal perceptions.

So let’s see what MCH Epidemiology actually means. All of us who choose to stay in the epidemiology field didn’t like to be challenged by developing epidemiological studies, coming up with different hypotheses, trying to test to find the right data for doing so, but we like it, so it’s fun. Let’s imagine that we have this epidemiology like an amusement park, and all are having fun trying to do this or to run these epidemiological studies. What do you think MCH Epidemiology is? The roller coaster, of course. Why? Because it is pretty challenging to ride it, but in the same time, it’s very attracting. We still have every year, many people joining the field. We have many people who were in the field for long regardless of these challenges.

So let’s see how these physical forces behind riding or having fun in riding the roller coaster can be reflected, or reflect, our MCH Epi work. When a roller coaster is designed, first of all, we have to have the height of the first field to determine the height of the first hill. What that means is the time on when an electric force is going to push us up to the hill -- the top of the hill to be able to do the rest in our life. If I like to translate, that would mean we like to be in a good school of public health with a good epidemiological program, so we have to push ourselves to reach that level. Then we have to select the shape of that hill. So we like -- what that means for us is to determine how fast the coaster can safely travel on the track, and the coaster will stay on the track. In other words, we have to clearly learn epidemiology. If we are unable, then we have to change our minds. Then we have to exit this path. We go out of school. So out of this hill, the exit should be designed in such a way to maintain the thrill of the ride, and yet provide a safe transition to the next stage of the ride. So this is when we get to have a job, and to go to the path that our predecessors paved for us.

Well, in real life it’s not as easy as it appears. When you get to your first job as an MCH epidemiologist, you get to have assigned different tasks that you are not perhaps familiar with, so you need to have training, you need to move on and to keep learning. There were, as you know, many debates in regards to functions of MCH epidemiologists but not clear resolution. There have been question raised as to whether MCH epidemiologists are not, in fact, more close to health service researchers or biostatisticians than epidemiologists.

I would assume that all of you read the editorial of MCH Journal issue of June 2005, when Greg Alexander and Michael Kogan very nicely explained to us what we mean where we are what -- how many trainings we had. And I like very much when they say that, “Living the matter of having the precise job definition, open for ongoing debate may be an advantage for the present as it will allow for innovation and flexibility in developing MCH Epidemiology training content that will be responsive to the emerging and changing needs in the MCH field.”

How this may translate to our roller coaster design? We need to have a second hill perhaps, and to select its height. That means we have to keep the thrill. We should be able to apply when we have our new job, to apply and to gain knowledge, but in the same time we should be able to keep learning. And they were right. We have to face different changes in the landscape of MCH, and I’m going to briefly go over a few of them; integration of genomics into public health, different population characteristics, and more information data collected.

You all know about the completion of Genomic -- Human Genome Project in 2003, and what that meant is a report published already by the Office of Genomic and Disease Prevention at the CDC. We have an increased understanding, actually, that most human diseases result from interaction between inherited genetic variation and numerous environmental factors. We understood what that means. We understood that genetic services’ ultimate goal is to reduce mortality and morbidity.

Well, we also understood by having the real application of genetics, genomics; two terms that are used exchangeable. Newborn screening, what that means. We have almost two-thirds of all babies born in United States screened for more than 20 life-threatening disorders, which means more children with different conditions that may need long-term healthcare.

You also heard, even in our plenary session at this MCH Epi Conference, about obesity in children and how this is a major issue. We have double obesity prevalence in children six to eleven years old, from seven percent in 1983 to 18.8 percent in 2004. And in those age 12 to 19, almost triple, like from five percent to 71 percent, which means another generation of overweight adults who may be at risk for subsequent overweight and obesity related health conditions. These are our children.

We have also mothers in MCH. So we have more mothers who give birth after age 35, 40 years who consider like a borderline in other -- in old or prior OB/GYN guidelines, this was considered like an old mother and was at risk. Maternal morbidity was brought to our attention and in publication American Journal of Public Health by (inaudible) Cynthia Berg, Christopher Johnson and Hani Atrash, first time saying a serious public health problem affecting nearly 1.7 million of women. Well, we understood also that among this condition, this pregnancy-induced problem, let’s say pregnancy-induced hypertension, occur more often in women with preexisting hypertension, and there are a subsequent risk for preterm morbidities and other issues.

I said we have more information. Yes, we have the ever-increasing amount of information. We have different data sources. We tried to link them. We tried to use to understand better. We have to know how to analyze this available information in a reliable way. We have to increase a critical evaluation of different study and to understand the advanced technical, statistical, and epidemiological methodologies.

Well, what this means actually to our roller coaster design, going back to our MCH roller coaster, it means we should add the loop. We should be aware and flexible and aware of different changes. We have to keep the thrill, but in the same time, to be able to adjust to the inversion to the other elements of the speed as the roller coaster design taught us.

We have other future challenges in front of us and different next steps to take. And again, as I said when I began talking, this -- let’s take this as my personal perceptions, and I’m bringing this up just because I want to challenge you to discuss around these issues. We understand where we began working on different issues related to women health beyond pregnancies we perhaps have to develop a better understanding. We may need to develop new data sources, maybe disease-specific registries or surveillance. We need to continue to explore the impact of chronic diseases debuting childhood. We need to define and strengthen our collaboration with chronic diseases between MCH and Chronic Disease Epidemiology. And we also have to explore the concept of life force approach in epidemiology.

And I am asking you, do you think this is new? Perhaps it’s not a new concept. And I’m reminding you what Pauline Stitt said. Pauline Stitt was born on May 28 of 1909, and she was a graduate of University of Michigan Medical School in 1933. She said, “All of the population, everybody of every age, we’re all at one time children and they bring into their maturity and old age their strength and scarce of an entire lifetime. All of tomorrow’s productive mature citizens are located today at some place along the MCH continuum, and they are at some point in their creation, either being conceived or born or nurtured for the years to come.”

I will leave it up to you to interpret this as perhaps a vision of Pauline Stitt long time ago, that it’s a continuum and you should see like a life-spent approach wherever we learn more and understand genomics, MCH and chronic disease.

So I challenge you to think, do we need to add new features to our roller coaster, or are we ready to ride a new MCH Epidemiology roller coaster of a different design maybe? So I guess this is just, as I said, to bring to your minds other questions, and what we should be thinking when we move along. And try to define -- and I don’t know if it’s important to define it, but perhaps to think what challenges are in front of us when we move ahead in MCH field. Thank you.