MCHB EPI Atlanta Conference
 
December 5 - 7, 2006

MCH Epidemiology: Mapping the Future

BAO-PING ZHU: Now, I’d like to invite the speakers up here. Before we start this discussion, I want to show you some ground rules about the discussion. I have left federal practice, federal employments, so I have more rights -- well, the goal of the ground -- well, by the way, the picture -- the caption, I can pretty much put everything up there, it would fit. The goal of this discussion is to hear from as many people as possible, so please use microphones. If you have an opinion, please use microphones and identify yourself. Otherwise you will say, “Hello, hello,” we can’t hear you. And then I would like you to limit your comment or question to less than one minute each, and I would like the speakers to limit your -- if you have to respond then limit your response to less than one minute each, try hard. I have a soft heart, so I can’t be hard on you and so have mercy on me as a moderator.

WILLIAM SAPPENFIELD: But the panel could be hard on you.

KEN ROSENBERG: Is my minute starting?

DEBORAH ROSENBERG: Yes.

WILLIAM SAPPENFIELD: Yes.

KEN ROSENBERG: I’m Ken Rosenberg from Oregon. I’m the lead MCH epidemiologist in Oregon. Deb really stimulated a line of thinking about what makes for an effective program. It is one line of thinking that -- it got me thinking about which is -- and first of all, we come from an area which historically was not data-driven and did not use data much until the last 10, 12 years. And those of us who are in state health departments find ourselves in many cases, as I am, with independent relationships with each of several programs. I have my own relationship with perinatal child health, adolescent, family planning, WIC immunization, et cetera. And it strikes me that there is one set of interactions that I’ve had with some programs that, to me, represent the most effective public health practice in my work. And that is that there are several programs that have met on a regular basis with epidemiologists in order to develop a research agenda driven by the program, carried out by the researchers that integrates the use of data, the thinking about data into advancing the agenda of the program. And that I think it must be very hard to capture that in any kind of quantitative survey; but I say that I think more as a piece of my experience that other people might want to share. A lot of what I do is I think about, “What do I want to do next that I’m not doing now? Is there some program over there that I perceive might be open to that kind of an hour or two hours once a month on a regular basis over a long period of time to develop a research agenda?”

DEBORAH ROSENBERG: Yeah, that reminded me -- that’s another one of those questions about complex directionalities. So I heard you saying it’s like you have an idea as an epidemiologist and you might approach the program; but also a program might have an idea and there is the environment now, it sounds like in Oregon, so that there is this back and forth that ideas are generated in -- on either side and that one hand washes the other. And I think that’s -- that is hard to capture and we’re doing our best.

WILLIAM SAPPENFIELD: Well, someone is going up, Deb. I guess one of the questions that came to mind is take the idea of a CDC assignee. That may be a strong potent force into your capacity model, but there were probably factors that actually led to the assignee being put there. And by putting the assignee in the model, those factors are now maybe not as significant. So in this process, there may need to be what I call sort of a domino effect of trying to analyze the different factors.

DEBORAH ROSENBERG: You just described a causal pathway problem. So, I mean, that’s another reason why we have multi-colinearity -- I mean, and that’s why we’re going to have different models; because you’re right, it’s very hard to know what proceeds what and there is a huge feedback loop here. This study team thinks very dialectically, let me just say that. So trying to describe the dialectics of everything that’s going on is challenging.

CAROLYN SLACK: Hello, I’m Carolyn Slack with Columbus Public Health, a local public health department. A couple of things I was thinking about. In terms of the sample size thing one thing struck me; have you thought about including -- querying large or city, county health departments where there is probably significant MCH Epidemiology effort within a state but not at the state health department? Then I have another question.

DEBORAH ROSENBERG: (Inaudible) that one again?

WILLIAM SAPPENFIELD: As Carolyn -- now, that’s a good question. We did do a survey once with City MatCH and NACCHO trying to look at this to some extent on a very -- a much less sophisticated level. And we asked them about their capacity and then we asked them about their perceived capacity of the state. And there was an extremely strong correlation when the state was not strong, their own perceived capacity of their own was less and vice versa. Now, there were clearly some key examples where the rule was broken, but there seems to be -- there seemed to be some relationship between the state and your larger urban communities having comparable collection. And it is even true down to the medium into the smaller health counties, and they were even more dependent upon that interaction with the state. But I don’t think we can look at that with the current views, but I think you raise important questions. When you talk about epidemiology within a state, it may not all necessarily be at the state.

CAROLYN SLACK: The other thought I was thinking about in terms of all the questions about the translation piece; what I just think within our department we have several -- I think we have -- I think six full-time epidemiologists, but we have several people within our department who are trained epidemiologists doing other work. And I wondered if you capture any of that in the survey and thought about there could be folks who aren’t calling themselves epidemiologists but were trained there doing other work and involved in that translating as I think we are at our department.

DEBORAH ROSENBERG: Yeah, we actually -- we asked about -- again, we have this concept of the MCH Epidemiology effort; so this was not about MCH epidemiologists per se. And we asked each state and D.C. -- we asked them to categorize staff that made up that effort and it included MCH epidemiologists, other analytics staff, IT staff. So we had a range of -- and what was the -- data managers. So, for instance, it might be that someone that manages the PRAMS data for example isn’t an epidemiologist, but they’re doing data work. So we try to ask about a broader ray of staff in the effort.

SHERRY SPENCE: Sherry Spence from somewhere on the Internet. You’ve talked about MCH capacity building and talked a little bit about the infrastructure that needs to be in place for that capacity to be built. And I’m wondering if there are any other things that you can add to that infrastructure piece. Schools of public health have MCH Epi programs now, in-state internships and fellowships are building capacity of MCH; but what about the connections with other programs and other departments? Other epidemiologists in the state? Other parts of the --

DEBORAH ROSENBERG: Sherry, I mean, just let me interrupt for a minute because the way you’ve even framed that -- see, I think we have to get out of -- that’s why we -- the lingo, we created this lingo of the MCH Epidemiology effort, and this was -- we had a long conversation about that -- I can’t remember -- with the advisory group. So we don’t think of MCH Epi as, for instance, just people working with the Title V. I mean it was -- it is maybe MC -- chronic disease epidemiologist. You know, we had this discussion about is the person doing the cervical cancer screening work? To me, that’s MCH Epidemiology, but we don’t often think that way. And that’s the way we’re trying to move in that direction of thinking about this effort that encompasses -- that’s not tied to a specific program including the Title V Program.

SHERRY SPENCE: Yeah, thanks. That's what I was getting at.

DEBORAH ROSENBERG: Yeah.

VIOLANDA GRIGORESCU: That may mean, sorry -- that was actually the message. Do we like to keep the same name? Do we like to redefine it? Do we need to redefine it? It’s a challenge, I guess, the fact that we experience some changes in the landscape of MCH. So how do you envision this? Because everybody is like talking about the MCH thinking perhaps of Title V, it’s much more beyond. Roger.

ROGER ROCHAT: Roger Rochat from Emory University. Just to pick up on that particular issue -- God, I’ve lost my thought.

DEBORAH ROSENBERG: I know the feeling.

ROGER ROCHAT: Then I’ll come back.

WILLIAM SAPPENFIELD: Well, to respond to the Title V thing; I think it’s very important even for some of us who were the first MCH epidemiologist out in the states, we were never limited or linked by Title V. We were mainly defined by what the agency needed to be addressed for the Maternal and Child Health population. So if there’s a linkage, it’s not necessarily a linkage for everybody from the conceptual perspective.

ROGER ROCHAT: My thought was really just a comment that the CSTE analysis doesn’t accommodate the kind of discussion that just took place. That is when epidemiologists are classified as ID or MCH, the MCH effort is not adequately described. It may be the 20 percent of the ID effort is on MCH or chronic disease on MCH. And that kind of categorization of the effort is missing from that. And then just on the populations that have changed -- and Violanda, you alluded to that well -- but there’s other changes; the massive immigration that’s been taking place and then the specialized populations, I’ll say, institutionalized, incarcerated, homeless. I mean, there’s a whole groupings that often get missed out, or may be better known to the local people than to the state level people. And then the other area that hasn’t been discussed are tribal epidemiologists. Again, tribal people often being not adequately addressed by state people or local county government maybe. And what’s the interaction or should be the interaction between the Tribal Epidemiology effort in the area of MCH and the state level? And I know some is taking place, but it’s relatively recent.

Violanda Grigorescu: Yes, and it’s a very good point. I was just trying to highlight a few of them, and it was hard to have in five minutes whatever we should be debating on today.

ARDEN HANDLER: I just wanted to make a comment. I’m Arden Handler. And Ken just walked out, but actually the question he asked was about who sets the agenda for MCH Epi? We actually asked that question, and as Deb showed, when the agenda was set in consensus and collaboration, we see effective MCH Epidemiology. We asked that question because we’ve done a prior study where it was clear that there were issues whether MCH was setting the agenda or whether EPI was setting the agenda. And we actually have some really pretty strong results that collaboration is really a key. And I just wanted to clarify that --

Violanda Grigorescu: Yes.

ARDEN HANDLER: -- because it’s really clear in the two models that Deb showed.

Michael COGAN: Hi, I’m Michael.

JUAN ACUÑA: I insist. I insist. How are you, Michael?

Michael COGAN: Fine one. How are you?

JUAN ACUÑA: We keep doing this all day long.

Michael COGAN: You know what?

JUAN ACUÑA: This is just destiny.

Michael COGAN: Don’t tell me the secrets that you’ve been telling me recently, but later.

JUAN ACUÑA: Oh, but we have a minute, so do we share?

BAO-PING ZHU: Michael first. Michael first.

JUAN ACUÑA: You always beat me by a nose, but that’s fine.

MICHAEL COGAN: I’m Michael Cogan from the Maternal and Child Health Bureau. And as soon as Roger mentioned that he couldn’t remember his question at first, I started writing mine down. Okay. So my question is, where is the best wine store? Oh, wait, I’m sorry. That’s my question for the concierge. I had another question I wrote down. When we’re talking about effective MCH Epidemiology, I focused on the word effective. And I want to know if in your survey, I couldn’t remember, if you asked states what is their biggest success story? In other words, why are we here? We’re not here to perpetuate our jobs, we’re here to perpetuate -- we’re here to better lives of mothers and children. And so did states talk about, well, we produced this data, which led to this program changing, which led to this outcome. Could you talk a little bit about that?

DEBORAH ROSENBERG: Yeah. We actually did ask that. Actually, we have some qualitative data about -- we asked states to highlight their most important work. But we also asked them directly about, “Has your data been used?” These were the intermediate outcomes. “Has your data been used in decision-making about development of new programs, in modification of existing programs, in even termination of programs? Has legislative change occurred?” Those were questions that it’s hard -- again, we could talk about all the misclassification issues there.

But also in our review, our qualitative review of the packets that states sent -- we were just talking about this back in Chicago about a week ago. It wasn’t a matter of quantity. Some states sent us FedEx boxes like this, and some states sent us like that. And for our outcome measure about effective MCH Epidemiology, it was much more about quality.

So what we were looking for were things like evidence of translation, evidence that legislation was mentioned. And it wasn’t just how many reports you had, but it was what was the interpretation. Was there also a document said about the connection between that report and some impact it had in the real world? But again, it was more -- it’s qualitative at this point, I would say. It’s really hard to quantify that. I don’t know if that answers your question, but that’s the best I can do for right now.

Female Speaker: What? It doesn’t have anything?

Deborah Rosenberg: By the way, see there was a dialectical relationship between HRSA and CDC that was (inaudible)..

JUAN ACUÑA: It’s always there. One of the science of achieving seniority in the field is that you stand up and forget your question if you don’t get to speak immediately. So I hear you, Roger.

MALE SPEAKER: (Inaudible).

JUAN ACUÑA: Yes. I have many questions. I mean, this is (inaudible) MCH Epidemiology Program at CDC. And from where I stand, I guess that that is very exciting to see that there is finally some data supporting your decisions to support the field from many, many different perspectives. I get that with 2,200 variables, there were many, many perspectives. The good thing with little sample sizes with too many variables is that you can fit the variables until they tell you what you want to say. But that’s another issue.

Deborah Rosenberg: We’re trying hard to avoid that.

JUAN ACUÑA: Yes. Yes. No, seriously. My question is going to be very specific to one of the fields that we cover, one of the topics as a program that we cover and is the future of this conference. Having what you have in the information that you have gathered and the perspective that you have presented, where do you think that we should go next? Where do you think that we should focus on and add on?

And I’m just going to (inaudible) a comment. I have heard that people have been happy with the conference quality, quantity, et cetera. But one of the most striking things that I saw at the conference was an informal session on mentoring last night. And it was amazing because of the number of students and people information that actually jumped into the session, and because of the number of mentors that showed to the session as well. So it ended up being a huge crowd in a very tiny room sharing two bags of peanuts that Roger brought. Thanks Roger. So I want to hear some ideas based on these concepts and these -- what would be your vision for where we should go next particularly with our conference?

Deborah Rosenberg: You’re asking me about the whole field, Juan, or about the conference and the conference itself, or what?

JUAN ACUÑA: Just shoot. I mean, I’m saying just brainstorm, discussing. For instance, one of the specific topics that we always have a hard time to try to come up with is plenaries. I mean, where should we go next? What is relevant for the field that we should be discussing and supporting given that we are MCH Epidemiology? Of course, we do not presume that everybody that works in the field is here; but I think that we have to accept that a lot of what is for the use in the field is shown here and makes it to the conference, people come, present, interact, network, et cetera, et cetera. So how can this conference better support the field of MCH Epi given what you have shown?

Deborah Rosenburg: Answer this.

KEN ROSENBERG: I have a couple of thoughts.

Violanda Grigorescu: I think.

Deborah Rosenburg: Yeah.

KEN ROSENBERG: I have no -- do you hear me?

Deborah Rosenburg: Yeah.

KEN ROSENBERG: Okay. It’s not clear to me these are implementable, but I have thoughts about where I’d like to see things go. The one that I think is probably most difficult to implement would be a fourth day.

Violanda Grigorescu: The what?

Ken ROSENBerg: My biggest problem in this conference is that the sessions I’m going to are wonderful and there are so many sessions that I’m not getting to and there are discussions that I want to be part of that I’m not able to. So if there’s some way to increase the number of sessions I can attend, that would be wonderful. The other piece -- see, I’m making notes too. The other piece is, there’s a -- when (inaudible) first asked us to do the western MCH Epi conference, the regional conference, his thought was, “Try doing more round tables and less scientific presentations.” And I think that was very successful for us and that it might be useful to try to implement some of that in this conference. One of the things that I’ve experienced has been, when we’ve had only three presentations in a session, there’s been more time for discussion. And often the discussion at the end of the session has been the most interesting and some of us have learned the most from. If there’s a way to either just keep down to a maximum of three presentations, or to actually structure entire hour and a half sessions around some kind of round table discussion, that would be fabulous.

WILLIAM SAPPENFIELD: I would second Ken’s suggestion. I actually think the idea of talking about the possibilities of some round tables on key or emerging issues that might be helpful if we had some stimulants because sometimes -- for us out in the field, having some of those conversations with people could be helpful.

Deborah Rosenburg: I wanted to answer on two levels. One more generically for the field, and then one about the conference and now we’re moving -- Violanda said we get to be biased here. So now a lot of what you’re going to hear is from me -- this isn’t -- okay. By the way, Violanda pointed out that the girls are on this side and the boys are on this side. Okay. So back to translation. I was sort of -- this is not about the conference but about in general. This whole idea of variability; we still have a long way to go, but there is going to be a time, hopefully sooner rather than later, where a lot of the data infrastructure issues that we’ve all been struggling with for the last 20 years are going to get somewhat resolved. More and more states are getting closer to having a technical environment that functions and that works for doing the MCH Epi work, and so then it’s moving out in that conceptual model more towards improvement of the outputs, what Michael was talking about. The having an impact; because often we’ve been soaked, we can’t even get the data to do the work so that we can have an impact. We’re getting there slowly but surely. And so maybe some of the next steps are focusing on that piece. Now my bias thing about the conference, which people on the planning committee have heard me say “Ad infinitum,” which is I really see -- it’s supporting also what Ken said but I would say it this way. At many scientific meetings, which you go -- you go hear presentations and you hear people’s results. And I think this conference for me, when it’s good for me as a professional, it’s more about both ends of the process. It’s hearing details about the methods that you don’t usually get when you’re just hearing the results, but also sort of the discussion section; details about the implications and how you do that translation work. How do you take these methods that have produced these results and then make them useful to people and make them -- have allowed there to be an environment where action can occur to affect the people we all care about, women and children and families. So I see the conference as one -- I want to have sessions that are methods and sort of policy level. And the results, to be honest, they’re all really good, but I’m less interested in them here. I can go other places to hear those.

Violanda Grigorescu: And there’s an idea of other topics. I really like Mary Roger’s work on using PRAMS to build the MCH chronic collaboration. So perhaps you want to consider having these kinds of topics and working on different things related to our population by crossing the bridge and trying to involve our partners. He hasn’t been presented here. I think Mary presented only at PRAMS meeting, but it’s a great idea. I think we should pursue in more other fields the same process. It’s just the thought. Again, we are bias, of course, yes. We keep highlighting.

Bao-Ping Zhu: I know I’m a moderator. I’m not supposed to offer my opinion, but I --

Deborah Rosenburg: Yes, you are. Yes, you are.

Bao-Ping Zhu: We have had this discussion on again, off again, which is to form a national organization. Like a -- for example, AMCHP has its own organization, CSTE has the state of (inaudible) has this organization that’s CSTE. The question -- we have had lots of this discussion about forming a national organization. The question is, is it necessary? If we do, then what are the goals of the organization? And then the other question is, how do we do it? I think these are all the questions that are unanswered.

WILLIAM SAPPENFIELD: I’d like to raise a question real quickly, which is the CSTE survey that I find to me is disturbing if we actually are building capacity, and it looks like we’re leaving more and more states behind in terms of saying they now have none to minimal. And I guess for some of us it’s been a struggle for most for (inaudible) to try to address, but I did not expect it to be actually increasing. And so I’m concerned, given what we’re learning Deb, I don’t know if you can give us insights into those states, or if anybody can help us fill in those gaps, but I consider that a very serious problem for the field.

Violanda Grigorescu: On it.

Deborah Rosenburg: I’m going to talk about it.

Violanda Grigorescu: Not yet.

Deborah Rosenburg: Somebody else will talk about it.

MidGE Mccoslin: My name is Midge McCoslin and I’m not an epidemiologist. So if you don’t mind, I just wanted to take a minute to share my perspective of this conference for my first time here. Is that okay?

MALE SPEAKER: Sure.

MidGE Mccoslin: I’m a nurse. I’ve been a Maternal and Child Health nurse for almost 40 years and I’m proud of it. But I’m sad to say that in the last two years that I’ve been a part of epidemiology that all this is coming at the twilight of my career. I wish I had been more involved. I mean -- and Violanda, I mean, she’s been a tremendous mentor. Nurses don’t mentor other nurses. And the one thing I have seen here these last three days is how much epidemiologists mentor their young. We don’t do that. They say nurses eat their young -- and I’m speaking for myself. I take from him. This is my perspective. I have always mentored. I’ve been the unusual person, but this has been a tremendous experience for me. I came to do a round table and I will say this, I had one person come to my round table when I did it. I brought my 75 copies like I was told but they have all gone out, out there. But I helped one person. One person came and we sat and we talked. And I told Violanda, if I have to do a report on this and somebody says, “How many people came,” it wasn’t the number. It was that I helped one person. And I’m leaving this conference with such a good feeling and I just felt like I had to share that from a nursing perspective. As you’re talking about where you want to go and what you want to do, as an outsider, so to speak, I think you’re doing great. I always thought statistics are something that you could manipulate to say what you want them to say, but I’ve learned a lot in three days. So I just wanted to share that.

Deborah Rosenburg: Thank you, Midge.

FEMALE SPEAKER: I was just wondering, Bill, if the effect that we’re seeing of increasing capacity and increasing lack of capacity is one of creating a demand that then grows with the capacity to fill it? And not so much that there’s less out there but there are higher expectations.

DEBORAH ROSENBERG: Yes.

JUAN ACUÑA: I didn’t see the slide in detail, but I believe that the percentages didn’t add to one hundred. So I interpreted that they --

WILLIAM SAPPENFIELD: No, they didn’t because there’s a sum. I did not report the sum.

JUAN ACUÑA: Yes. So the way that I interpreted was that the percentage of minimal were none before. So from -- jumping from none to minimal, I assume that it was good. But then again I might be wrong.

Bao-Ping Zhu: I see that you’re well trained.

JUAN ACUÑA: Yes. So I thought that 70 percent meant that we jumped from 35 percent in 2001 to an overall 50 plus 20 something, 70 something percent, and that the green is an increase from the none?

WILLIAM SAPPENFIELD: No. It’s really the sum that’s dividing and going in two directions. The sum are either moving to have insubstantial to full, or they’re moving to having minimal to none.

JUAN ACUÑA: Oh, okay. So we have a problem, don’t we?

WILLIAM SAPPENFIELD: In my opinion, we have a major problem. Now, it could be clearly expectations, but those may be that there are now even more realistic about the expectations of what they need; so that part may be healthy, but the not having it is not healthy.

JUDITH THIERRY: That’s a great slide to -- for my question. I’m Judith Thierry; I’m a Maternal and Child Health Coordinator for the Indian Health Service. There’s a widening of the gap, so I’m wondering about the state-to-state interactions and the shared resources that with the economic picture that we have that all states were not created equal, their various sizes, the rurality, the ruckus, if you will. We’ve seen methamphetamine cross borders, people cross borders with Katrina, we have the south border issues, and if you look at Alaska, we have circum-polar issues that really extend beyond states and beyond what we determine as countries. So I’d like to hear what your issue -- what you’ve addressed in these -- in your methodology around state-to-state interactions? Thanks.

DEBORAH ROSENBERG: That’s actually a great question. I am going to have to think about that for a while. One thing I was going to say is that we were -- we went into this thinking that we’re going to maybe have to even have smaller sample size and do stratified analysis because we recognized that there was -- we had lots of discussions with Roger about this, about really small states, rural states; and while we haven’t -- I’m not sure yet. Things aren’t looking -- I mean, there are lots of what we might have intuitively thought of would be states that didn’t have a lot of capacity. Some of those are doing really well. So that’s no answer to you, but I think it’s an important question. I’m not sure that we’re going to be able to do exactly what you rightly think should be analyzed.

WILLIAM SAPPENFIELD: Well, the regional epidemiology conferences would be, at least, an obvious conspicuous piece of that. If I could add one more comment it would be, Bao-Ping, in response to developing a national organization, with your aspirations of going to China, we need a global organization that would just might be a kick off in this country.

BAO-PING ZHU: I think Roger has the last word.

DEBORAH ROSENBERG: Can I just say one more thing?

BAO-PING ZHU: Yes, sure.

DEBORAH ROSENBERG: Well, I just want to say another thank you, first of all. But also, just let’s walk out of here, I just realized for myself too that the one thing --

VIOLANDA GRIGORESCU: There’s someone else.

DEBORAH ROSENBERG: Okay. The one thing as usual that we are -- sort of shy away from talking about is the big political context. I mean, why are state budgets in the shape that they’re in? We didn’t talk about that, so.

BAO PING ZHU: Thank you, everyone.

VIOLANDA GRIGORESCU: We have somebody. I’ll call her.

BAO-PING ZHU: All right. One more question.

GIOGLIOLA BARUFFI: Yeah. If you don’t mind? Okay. I’m Giogliola Baruffi from the University of Hawaii. I’m a professor there in Maternal and Child Health. And I wanted to comment also in relation to this maybe number of state that need more epidemiologists in MCH. At the university level, at least in my place, we have an epidemiology branch and an epidemiology major, with very, very well-trained epidemiologists, good; but there is no way that I can make them understand what’s -- not MCH Epidemiology, but why they don’t come in and use MCH or MCH issue in an epidemiological way, you say. And there is that complete separation. So in some of the states -- now, I am not sure at the state of Hawaii there are epidemiologists in infectious diseases, HIV, all sorts of epidemiologists, but do they -- does MCH utilize them or do they provide? Are they willing? Are they a help for MCH? At the university level, in my department, it’s not. It’s very difficult to have that support from the epidemiologists. So I don’t know whether you have a suggestion on how to do that, how to encourage that. With the other MCH School of Public Health how do they collaborate with their own epidemiology department? And how is that issue resolved because it doesn’t make sense.

WILLIAM SAPPENFIELD: The key is -- as I have to agree with you, I don’t think it’s resolved. I can talk to you about one major school of public health where the EPI department doesn’t talk about vital records at all. It takes the MCH department to teach anybody that they actually exist, and they don’t even consider surveillance to be epidemiology. So their epidemiologists are coming out with no concept of any of what we would call some of the public health tools that are necessary to be addressed. And many departments -- Michael, you may want to talk about it. But the funded programs for doctoral degrees in MCH Epidemiology somewhere in the MCH department with support from EPI, because the EPI people are not at all even interested in talking about it. They’ll let you take their classes.

VIOLANDA GRIGORESCU: I (inaudible) know the school of public health as I am at the state department, but I found it really useful to have the MCH section within the Bureau of Epidemiology and to be able to have the staff interacting with different other epidemiologists in other fields like infectious disease, like chronic disease, like those even working on bio terrorism. We have different seminars and that was really helpful to make others knowing about our work as well as having MCH epidemiologists learning about other tools. So I don’t know in academic institution, but I found useful as a state department.

BAO-PING ZHU: Michael, do you want to comment? Yeah. Well, if not you have one more question?

WILLIAM SAPPENFIELD: We are hoping that the applied competencies coming out by CDC and CSTE might help make departments of epidemiology or schools of public health more relevant to it.

SARA PATON: I just wanted to comment. My name is Sara Paton and I’m an epidemiologist in Dayton, Ohio and I have kind of an interesting position; I’m half at the academe and half in public health. I’m actually employed by the University of Wright State and they contract with me -- the local health district contracts with me to bring academia to public health. So I listened to our last question and comments about how to integrate the two, and it’s a commitment that our community has made in our MPH Program and our Health District to combine the two. So in my EPI class that I teach, I have a public health epidemiologist come in and teach about surveillance and I have someone come in and teach about survey questions and what real public health EPI does as well as the -- how to calculate an odds ratio. So I just wanted to comment that was one way we integrate the two.

BAO-PING ZHU: Thank you very much. Thank you. Thank you everyone for staying late and thank you.