MCHB ALL GRANTEES MEETING

Identifying Critical MCH Challenges

October 4-7, 2004

GREG ALEXANDER: Thank you, Ann. I want to tell a little story to start this. It was some months ago that Cassie Lauver called me to give me an update on a meeting that I had missed. I was on the Planning Committee for this meeting, and as you all know what happens when you miss meetings. But she called me to tell me about this great idea they had, this plenary opening panel, this Oprah Winfrey idea. And I, who have never seen Oprah Winfrey's show, and feeling rather safe, could say, "Great idea. I think that's wonderful," because what did I know? And there was a pause in the conversation, and then I snapped to attention, because my sixth sense snapped in. And like an animal with the crosshairs coming to bear, I felt the shock coming. "And you, we all know that you will make the perfect Oprah Winfrey."

Now, I ask you to look at these screens carefully, and ask yourself if you were asked to fill the role of Oprah Winfrey, does this picture come to mind? Is this what you would do? There's a casting job for you somewhere. Well, look under your chairs please. Do any of you see a car there? If you do, it's mine. Do I look like I have lost weight in the last decade? Have you ever seen me show up in a meeting, and I've been in many meetings with many of you, have you heard me turn to a colleague and say, "You go, girl." What were they thinking? I told my wife, and she said, "Oh, that's wonderful. You have so much fun." And then she informs me that she's moving to Florida , and she is. Oh, well. There are good things about this. One, I love the topic. I wish I could play Dean Martin; I'm good at that. But I love this topic, and it's going to be a good conversation, and we're going to have fun mainly because I've got a great panel. And that's the key.

But I want all of you to have fun with this. As fun as, you know, I could have been other characters from talk shows. I could have been my friend's favorite talk show person, Jerry, but that seemed inappropriate for the group. So let me introduce this great panel. We'll start first with our local health representative, Peter Morris, Medical Director of Wake County Human Services North Carolina. Peter, join me on stage.

GREG ALEXANDER: I can have fun with this. Doug Paterson, our State Representative Director of the Bureau of Family and Child Health Michigan Department of Community (Inaudible).

GREG ALEXANDER: Good team. Next, our Federal Representative, Duane Alexander, Director of the National Institute of Child Health and Human Development.

GREG ALEXANDER: Now, from the foundation perspective, Ed Schor, Assistant Vice-President of the Commonwealth Fund.

GREG ALEXANDER: Now, just so you don't remember this session as an aging Ophry--Opie, maybe I should say that, interviewing guys in suits, we have Connie Wells, Executive Director of the Florida Institute of Family Involvement.

GREG ALEXANDER: See, we can have fun. My wife will be pleased. Maybe I'll join her in Florida . I think I will. We're going to start our discussion. I have some general questions for our panel, but I've encouraged them to interact with each other freely, to just not answer my questions, but to ask each other. And we're going to start this with, first, a discussion of what I see as a challenge that we all have faced. It's certainly one through my entire professional career. I've been living in this period fiscal constraint and limited resources. And I think all of us have gotten used to working with limited resources, trying to meet the needs of folks around us, while at the same time maintaining quality. I can imagine this certainly must be a challenge at the local level. But, you know, this field has a legacy of leadership. It has a legacy of rising up, overcoming challenges of the moment. So I want to start our discussion today talking about and celebrating our successes. So I start with you, Peter. What do you see as our successes and ongoing opportunities? And I want to hear about your challenges as well, but let's start on an upbeat note with accomplishments. Peter?

PETER MORRIS: Thank you. It's always a challenge to start on an upbeat note at a time when perhaps things aren’t going as well as we want for women, infants, children in our agencies. But let me say that what I think we have been doing and I think what you have been doing at the local level in many ways is reframing ourselves. In my case, we reframed ourselves rather dramatically. We've moved from being a health department to being an integrated human service agency with health, mental health, and social services together under one roof. We also moved to reframe our problems as visions, and in my case again, we were allowed to rename our services, and this may be one of our problems for the day, because can you find maternal and child health in local agencies? We have changed our names. We go by aliases, but we decided to by the alias Family and Youth Success. We decided to describe where it is we wanted to go, and we also, as you have, reframed our strategies.

So let me say that in these reframings, you could ask, "So who does the work?" And in my community, more women receive more effective contraception with decreases in our teen pregnancy rate largely because our clinics did not get bigger, but because our partners within the community have gotten larger and more effective in serving the demographics of our population. More children receive more immunizations and more well child visits, not again, solely because of our efforts as a provider, but because more pediatricians see these children in their offices and provide medical homes for them. More pregnant women are receiving more prenatal care than ever before, and if only for the stats that had been released just last month, I could have told you that we continued our run towards a decreased infant mortality rate and the first time we brought our non-white infant mortality rate into single digits. How did we do it? Again, not by ourselves. More of our African-American pregnant women are seen in the private sector, and we are their safety net providers.

We see more of the Latinos, we see more of the Eastern Africans, we see more of the Eastern Europeans. We're filling a new niche, if you will, in delivering care more than before. So when you look at what happened in terms of who does the work, we still are out there doing the work, but we reframed who we might get it done with, and we've seen improvements in each of our indicators. Well, how do you redefine the problem? In my case, what we decided to do is redefine the problem with more integration as a human service agency, but I suspect you've done some of these strategies, as well. We decided to address not simply the health services or the preventive services we can deliver, but what about the economic services? Isn't there an underlying issue of how well are our families doing? More families and children receive Medicaid than ever before in the history of my county. More children participating in the state children's health insurance program in North Carolina called Health Choice than before.

More children and families receiving child daycare subsidy, more families receiving Food Stamps, more rental housing, not enough, more housing assistance, not enough occurring within our community to try and support who we serve. Well, we reached out to our school system, and said, "Why do we let children perform below grade level?" And we basically said, "How about we embrace a common goal that 95 percent of our children should perform at grade level by the year 2003?" Folks, we missed it. We didn't quite get there, but we moved the number up from 84 percent to 93 percent, and not to get you with a lot of statistics, but we did it by saying, "What's the public health intervention that improves educational success?" We've reframed the problem. School nurses weren't going to be rewarded by how many screenings they did, they were going to be rewarded by the end of grade test scores in their schools. What would you do to improve end of grade test scores among the children you serve?

Similarly, we said, "You know, I wonder what we should do to engage those families whose kids are not doing well in school?" What do you do with someone who didn't do well in school themselves? They don't want to talk to the teacher. They don't want to approach the principal. And we've began doing more family outreach and more family support to assist them in wondering how it is they express their needs, their desires, and their hopes for their children. And finally, we reframed, if you will, the engagement. There was a time there within this partnership thing that we were really not doing much to help the obesity of the United States, because I met for breakfast and lunch with the same group of people day in and day out, week in and week out, because you know there are only so many partners within the community.

But I think we decided that it wasn't really the meetings, it was about the relationships. It was about trust and getting to the point where our community agencies could name the solutions, the solutions that might embarrass us so frankly we do deliver more services, and we deliver them at more hours in the evenings and on weekends, because that's what our consumers told us they needed. But you know, we also go hand in hand with more advocacy in partnership with families, professional organizations, community action groups going forward to say, "This is what we need, and this is why we need it." And yes, actually we have more understanding from our elected officials. Yes, we actually got more taxes from our conservative elected officials, because we were able to articulate a need and a strategy, which they voted for.

Now, the problem of this litany, if you will, of more is, you know, part of it is more growth in my community. I live in one of the fastest growing communities in North Carolina . Part of it is the downturn in the economy, more Medicaid, more Food Stamps, more WIC, more this. Well, part of it is because more distress, more families in need. But we did connect those families in need to more services. And part of it, and I think a challenge for this discussion today, is we do more of what we know how to do, which isn't necessarily what needs to be done. And the challenge at the local is to say, "Do we simply deliver the services more and more and more," or do we say, "There comes a point that where we delivered enough of this, and the intervention needs to be different."

GREG ALEXANDER: Thank you, Peter. You mentioned about changing the name of MCH. What are the pluses and minuses of that? I know that AMCHP has struggled with this. Any--either one of you want to comment?

UNIDENTIFIED SPEAKER : No.

GREG ALEXANDER: I warned you about that.

PETER MORRIS: The quick answer would be that at the community level, I'm not certain they ever knew us as MCH. Think at the community level, I think they knew us as a certain type of program or they would come in and say, "I'm here to get my baby shots." And, you know, I hate to use the McDonald's analogy, because after all they are--they're not the enemy, but they're part of our issue in addressing obesity. But what we learned to basically say is, "Well, gosh, you're here for an immunization, can I give an order of well childcare? Would you like a side of WIC? How about some Food Stamps with that?" No. I’m serious, we integrated our services, and they never knew what to call us anyway. We simply made our services more available. But frankly, it made a difference to us when we called ourselves something different, because you can't introduce yourself as being interested in family and youth success without somebody asking, "And how are you going to do that?"

DOUG PATERSON: Two comments if I could. One, I think it continues to be the struggle to try to help the public understand what public health is; not just MCH. And so many times, people think of public health as the physical health, the insurance role and medical care. And I think there is still a lot of confusion between public health and medical care. I think one of the great accomplishments at the local level that he didn't mentioned, I'd like to add, has been the growth of the science of epidemiology and the appreciation of it. When I first came to work for the State Health Department in Michigan , we had two epidemiologists in the entire department, and one of them was running our Bureau of Laboratories and the other was running our BRFS. We've seen a great increase in capacity. Again, a lot of appreciation for capacity building that's come to us from the federal government, but the locals have also begun to hire epidemiologists, and this is the science of public health. And I think we have made an accomplishment in the last 10 to 20 years in improving the capacity of developing our programs and science, and I think the locals have benefited from that. And I think they're beginning to recognize that and build their capacity, as well.

ED SCHOR:You've triggered a couple of things for me, Peter. I remember when I was in state government someone protesting the proposals suggested that she'd never seen a reorganization solve a problem. But I think that's not 100 percent correct. It sounds like your reorganization and bringing together a variety of human service people actually did make a difference, which reminds me of something that one of my colleagues said to me sometime in the last year. And that is that change is a contact sport. You know, it only happens when people bump into other people. A corollary of that is that a website is not an initiative. You know, it really takes bringing people together and looking for the common grounds and the common vision that's going to make the difference.

PETER MORRIS: Just to build on my colleagues, what I can say is that this human services agency really has embraced a community public health, epidemiology based approach to all services so it’s not simply a matter of folks who might have considered their job to be income maintenance caseworkers, i.e., to take applications for Foods Stamps or Medicaid. They too begin to embrace the outcomes, because we say, "This is what we want to do, and this is the population we need to receive." You can't be satisfied with your doors being opened from here to here and saying, "Well, did this today." Because we have the information that says who isn't being served, why aren't they being served, and why aren't we doing something about that? And that is the public health epidemiology approach that got us there.

GREG ALEXANDER: Peter, before I let you off the hook, since I'm having so much fun with you, I want to follow up on one other question that you mentioned about education. What opportunities are there to expand our partnerships with education that we maybe have not explored? And what successes have we gotten?

PETER MORRIS: Well I think at the local level, if you were to say, "What are their collaborations with education?" the things that will come to mind are do you have school health nurses? Do you have a school-based clinic? And these are not bad answers don't get me wrong. I just don't think they're sufficient answers, because if you look at the struggle of most teachers, even in my community, which is a relatively affluent community, what you see is an influx of students of various ethnicities. And boy, have we been challenged with that in our school? I know some of you come from communities where it's more, but there are now 49 languages spoken in our public schools. We struggle with whether we are identifying children for the early intervention programs in a timely fashion. Are they actually coming to school healthy and ready to learn, or are we identifying them late in kindergarten and first grade and seeing that they actually need remedial services then? Similarly in our childcare centers, are your childcare centers warehousing children while parents go to work, or are they a source for where you can begin to do infant stimulation, encourage the childcare professionals to do something more than perhaps place a child before the screen--a TV screen, and I mean no insult to these providers. They are underpaid, challenged in their work and given few resources.

But again in my community, in my state, a project called Smart Start has poured extra dollars into those communities and said, "What is it you really want to dream for in your children?" And I think if you think dream, and you think your dream for your children or your grandchildren, you would say there are opportunities for us to get into the education system. But we know, we tried for years knocking on the door and saying, "Hey, how about obesity? Hey, how about immunizations? Hey how about Hepatitis B in the sixth grade?" And when they said, "How about educational success? How about all children performing at grade level?" And we said, "Yes. We'll use our health and human services interventions to reach your goal." That's when the partnership began. It's listening to them.

GREG ALEXANDER: Thank you. Next, I want to change our focus just a little bit. During the last year, I've been fortunate enough to work with MCHB in the states on helping states with their needs assessment. I've been really impressed to the extent to which states have built their capacity for needs assessment, and I think it continues to grow. But, and I'll pick up on the comment about change, often when we find new needs, I wonder if states are equally at a position, and this is not a criticism in this case about states. It's more of a criticism to where we are with evaluation. Do we, when faced with new needs, do we do the same things we always did, and the same programs we always had? To what extent is there good evaluation information to tell us what new cost-effective programs and interventions are out there? And I worry if that capacity is keeping up with our needs assessment capacity. So now, I'll turn my attention to Doug, to you in the state level. What challenges do you see in the areas of improving health outcomes, health utilization outcomes and maintaining accountability, which is what needs assessment, evaluation and this planning cycle is all about.

DOUG PATERSON: How many of you read the book, FutureShock? I feel like I'm living in that age. It talked about the age of information and being bombarded by information all the time, and frankly, one of the frustrations for me, many times, is not lack of information, it's too much information. It's getting things all the time about new programs and new initiatives and I truly believe in the principle that you move toward what you focus on, and sometimes I think our challenge truly is trying to identify what those things we focus on, because the expectations of us are so broad. As Dr. Koop said, I don't know that we've been very successful in adopting violence as a public health issue. I think it's something we should, but I think it's competing with obesity, as an example that just came to the top of my head, and other issues that, frankly for lack of attention for a lot of years, is now becoming a public health crisis. So frankly I think some of the challenges as I just pointed out, I think, I love and appreciate epidemiology and the science and the information, because I think we need to work smarter, but I think we need to articulate our focus.

I think that's truly one of the challenges, because we aren't doing things as well as other states, and when that's pointed out to me, I think, "Oh, boy. This is something that we have to give more attention to." I think another challenge is marketing. I think Dr. Koop, again, did an excellent job this morning of talking about how well the tobacco industry understands the importance of marketing. And I think we have to bring marketing into the foray of public health as an absolute and necessary (inaudible). We need marketing expertise right out of the marketing experience to compete and to get our messages out, because that's going to be our challenge for the next ten years. And collaboration--I want to challenge all of you to count how many times that word is used everyday. And then I want to give you a definition of it, and I want to challenge you to measure when that word is used, whether it's being used in the correct context, because I think we have totally bastardized that word. It means shared ownership, shared decision-making and shared responsibility. It doesn't mean I called these people to the meeting, and they came and we talked about it for a little while. And I'm pleased at the words there, because I think it does have value, but really don't think--I think we still have a long way to go to practice it. So when somebody uses it, stop them, and ask them whether they really are sharing their people and sharing their money in that area. And my guess is you'll find it doesn't meet the litmus test very much.

And the other challenge, I think, which Peter eluded to is that we do need to collaborate, and we need to understand how our mission and how our messages do relate to the social services agencies and to the education agencies. I don't think you have to reorganize to do it. I think you have to have the vision and the leadership to understand what are the results that we want? What are we going to measure to determine those results? Those of you may recognize the work of Mark Freedman in results based accountability, but it's just logical sense. What do we want? How are we going to measure it? And what's the trend look like in what we're trying to measure and how are we going to impact that? It's not rocket science, but we do, I think, need to instill that more and around those results help everybody understand what they can do to contribute to that, and begin to focus more of our resources out of our, another famous word that's politically correct, silos, but out of our special areas of interest, and understand we're going to have to do business differently.

GREG ALEXANDER: Very good. Doug, we hear a lot about evidence-based results, research, programs; how much do we have to go? How much success have we had so far?

DOUG PATERSON: I'm a big believer in it, but I also don't think that it should become a barrier to trying new things, because I think too many times if there isn't evidence and there isn't science behind it, it means it's not worthwhile doing. But I think there are very good practices that do have good evidence behind them, and I appreciate the work of guys like Doug Kirby who have looked very, very comprehensively at teen pregnancy prevention programs. And while he said that for a long time there really weren't any good programs, he has identified four or five models now that meet that evidence, and I really think that that's where we need to begin, you know, investing. I appreciate having that kind of information come to me, being able to pick from those four or five and know that I can expect it will have some result.

GREG ALEXANDER: Ed, you wanted to comment?

ED SCHOR: Yeah, I think we’ve been tyrannized by this focus on evidence-based. I came in last evening to the last part of this general session, and Peter was responding to a question about outcomes and the difficulty of being held to accountability for outcomes when we really knew that we had to approximate some processes first. And we do ourselves a disservice by forcing ourselves to worry too much about evidence in advance of having that evidence. And, frankly, for preventive services, we will never have evidence for a lot of the things we do. Meaning that we will have evidence that will show that you can go from point A to point B. Okay, if you do the right things, you can reduce low birth weight rates, and we will then show that if you reduce low birth weight rates, you will reduce infant mortality. You go from A to B and B to C, but our ability to be able to prove A to C; we may never get there in many cases. And we shouldn't hold ourselves to that. If we have the science, and can logically prove that A goes to B, and B goes to C, we ought to be satisfied with that, and not worry so much about the evidence base for other things.

GREG ALEXANDER: Connie. Good. We've been waiting for you.

CONNI WELLS: Well, I think, just a note on that that I'd like to add is families--we've been hearing for decades about best practices and everybody got to decide whether they had a best practice or not, and there wasn't a uniformed checklist to say, "If you have this, you have a best practice. If you don't have this, you don't have a best practice." And while I agree with my colleague here about evidence-based practice, I think that we need to find something in between so that there's some more consistency and some assurances that what we're being told is really the best thing to do is actually, in reality, the best thing to do. Not one individual or one group's idea of what needs to be done based on a program and not on a process.

GREG ALEXANDER: Duane?

DUANE ALEXANDER: Well, as a person who has been very heavily involved in research in this area, I have to take a little bit of exception to any questions about the evidence-based practice and evidence-based research. Very clearly, there are some things that are going to be difficult to put to that kind of a test, and in those instances, we do the best we can. But there are instances, very clearly, where public health, medical practice in general, and maternal and child health in particular, are being called to question. People accuse us of two things. First of all, not applying what we know. And second, not knowing whether what we're doing is effective or not. And this really does have basis in fact. For example, much of what we do may make sense, but it hasn't been demonstrated to be safe or effective in clinical trails. And the best case in point of that in recent years has been the issue of tummy sleeping to avoid aspiration or SIDS. This was such a completely logical thing to do. It was a universal practice.

We all put our babies down on their tummies to sleep to avoid aspiration, pneumonia, or Sudden Infant Death Syndrome. But when this was subject to research, this universal practice, this thing that made eminent sense, was in fact shown to have a five to eight fold greater risk of the baby dying from SIDS compared to babies that slept on their backs. And so we decided we needed to try to change that practice. And the only way we could do it was through a partnership. It required a major effort, but we formed that partnership with the Maternal and Child Health Bureau, with NICHD, with other public health service agencies and outside the government with the American Academy of Pediatrics, with the SIDS professional organizations and advocacy groups. And together that partnership launched the Back to Sleep campaign that in less than ten years cut the SIDS rate in half by just changing the position we put our babies down to sleep in. So there are practices that need to be questioned and challenged if, in fact, we are going to provide the best care for our children.

The Back to Sleep campaign has been very successful, but there are pockets that still need to be addressed. The African American SIDS rate remains over two times the rate of the Caucasian population. And the American Indian and the Alaska native rates remain two to three times as high. So once again, we are forming partnerships. In the African American community, we formed partnerships with Alpha Kappa Alpha Sorority, with the women of the American Medical Association, with the organization called 1000 Black Women and these organizations are partnering with us to get the message out in a believable forum, in an effective forum at a community basis. And we hope to change that ratio that's existed. Similarly with the American Indian and the Alaska natives, we're working with the tribal councils, with the Indian health service, again, to try to get that message out. But this change shows what can be done with good science and good partnerships in making it apply.

A similar story could be told with teenage pregnancy, with births to girls 15 to 17 years of age that over the same period of time has also been cut about in half through a variety of efforts, leading among these, the national campaign to prevent teenage pregnancy. So this shows what can be with partnerships and with science. There are other practices that need this kind of examination. We need to look at the issue, for example of perinatal home visits before or after pregnancy, after birth, to look at whether or not they can be effective in reducing infant mortality and reducing SIDS as pilot programs have suggested they may be. We need to look very critically at this issue of a wider introduction of 17 Alpha-hydroxy progesterone as a way of reducing repeat premature birth, as well as possibly a way of reducing the prevalence of pre-term birth in women with multiple gestations or in women with other complications. We also have other areas, particularly in health behaviors, where we need to test other interventions. Whether it's in nutrition and activity, as Dr. Koop talked about, or an avoidance of tobacco, or alcohol, or drugs, or in the areas of appropriate behavior with driving, or with sex, or other activities.

All of these need to be tested in innovative ways to find more effective ways to do what we know needs to be done. One of the other efforts we need to do is to discover new possible interventions. And one way we're trying to do this is with one of the largest longitudinal birth cohort studies ever attempted, The National Children's Study. This is an effort to recruit 100,000 women during or before pregnancy following them during their pregnancy and looking at environmental influences on the outcome of that pregnancy, not only immediately, but as their children grow and develop to age 21. The first outcomes we will have measures of will be indicators of pre-term birth, low birth weight, birth defects and other problems in problematic outcomes of pregnancy and exposures in the first few months of life.

This is a way that we can gather information for developing and testing additional hypotheses and other new interventions. Here we'll take a partnership to launch this study. This is not a simple study; it's a very complicated one. It involves probably setting up recruitment sites around 100 different communities in the United States . It also is an expensive one. It will cost over the whole period of the study about $2,500,000,000.00 for 25 years to follow these kids to age 21. It will take a partnership to get the resources that we need to do this study. But if you look at the potential value of this study, if we could just make a reduction of three to five percent in some of these things that we're looking at in autism, in obesity, in asthma, in low birth weight, in learning problems, any of these would repay in cost in one year more than the entire cost of the study over 25 years. So we need to forge the partnerships that are necessary to do this. We really then have to discover new ways to improve maternal and child health, to transfer research to practice and to make all practice as evidence-based as we can do it.

DOUG PATERSON: That was a long answer. I also think we spend way too much time trying to reinvent wheels. I do think that there are many people in many communities that are working to do some of the same things that we begin to, and often we think we're the first ones, and we have to create a commission and so on. And I think that if we spend more time trying to locate and identify, I don't think that there's a whole lot new that's been challenged or created. I think we need to put more effort into that. That's just my own feeling.

GREG ALEXANDER: Other comments? I'm going to give one of my own. I've noticed that we have spent a lot of time using the term "from data to action". And I believe in that, but I'd like to close that circle and say we also need to spend equal amount of time from action to data. Where is the data to evaluate our actions, to change what we do again and keep that cycle going? So from data to action, action to data, because I think that helps all of us in being good stewards and accountable for what we do. I also want to continue with Duane just briefly before you go. I know you have to leave early. I sit at a University, I undertake research, but at the same time we are involved in the education of the future public health leaders that will be your colleagues. And it's a real tension between balancing those priorities as universities encourage us more and more to bring in grants, to bring in indirect costs sometimes at the trade-off of education and developing strong public health workforce. I know we have made great strides, but I wonder to what extent we are first able to take the science we have, and are there opportunities to move it more quickly into the public and private sector for direct applications of dissemination of results and are there ways to more involve our faculty and encourage them to do service, public health service, and to be involved with states and locals in their research. Any comments? And I'll open this up for everyone, as well.

DUANE ALEXANDER: Let me just start. Clearly, the opportunities are there. There are research dollars for this available from NICHD, from the Maternal and Child Health Bureau, from the Agency of Healthcare Research and Quality, and other federal agencies, as well. So the resources are there, not enormously, but they are there. But we find increasing impediments to using them. One, for example, relates to the practice liability insurance issue in obstetrics and gynecology. Physicians in this especially are increasingly being required to earn their medical malpractice premium, which now is in the realm of $100,000 from their patient care services before they can spend time to do research. So this is a real impediment that physicians in this specialty area of particular interest to maternal and child health have to face. So this is something that clearly has to be on the national agenda and be dealt with. Otherwise we are trying to provide our stimuli to resurge in a variety of ways.

Establishment of research networks, for example from NICHD of research network in maternal and fetal medicine as well as in neonatology. These networks have been in place now for about 15 years and have contributed significantly to the understanding that we have about the care for newborn infants, particularly preemies, as well as improved practice care during pregnancy. We also have a new network in stillbirth, trying to understand this as a cause of fetal loss and deal with this as a problem that can be improved if we gather the additional information. Many clinical trials are being done in Maternal and Child Health through these networks and there are opportunities as well for partnerships again with the federal agencies, with ARC and at NICHD with the Maternal and Child Health Bureau at NICHD and others. So the opportunity is there for doing the research, as well as to get the training that people need in order to be prepared to do this work. One of the things that we're doing is working in epidemiology, which has been talked about here trying to encourage epidemiology training programs in Maternal and Child Health and perinatal medicine and work with the community to get these going.

PETER MORRIS: If I can join on that to say that our organization because of its access to large numbers of patients has been a place where more faculty have received tenure at the University of North Carolina School of Public Health probably than any other community site by doing research and study. Having the researchers onsite engages our staff, engages our clients, and makes us be more excited about what we’re doing. It has moved more of us to seek those degrees in public health, the Masters in Public Health and Maternal Child Health. It changes the way we think. It would be a horrible loss to see research take over in our schools of public and practice suffer. So I can only hope that whatever is motivating universities to say, "Cover indirect costs. Get those grants and don't lose the training," it's incredibly important for those of us out in the field to have it. An area that I'd make appeals for is the appeal in how we're engaging our client's call it behavioral health, call it interventional counseling, call it motivational counseling, but there are lessons to be learned out there how we engage folks to consider quitting smoking, how to engage folks to adopt healthier lifestyles, how to engage folks how to eat better, exercise more, and those of us at the front line don’t know enough about how to apply those to our clients, and we need to hear from the researchers and others how we can best use that limited amount of time we have with clients to the best effect.

GREG ALEXANDER: Thank you, Peter. Ed, I know before you assumed your role recently at the Commonwealth Fund. You've served both at the state level and at universities, now; I'm interested in your perspective on the role of MCH. Clearly the healthcare system continues to evolve, and as such, public health system is evolving with it. But the basic developmental needs, the well-being needs of children have not changed all that much. So I'm going to give you the easy question of the morning: Has the role of MCH changed? Where is it going? Where should it go? And in the big picture, what are its challenges and opportunities today? Just in ten minutes if you would, please.

ED SCHOR: Actually I think my colleagues have answered a lot of that already. I think, maybe it's being a former MCHer, bit I think MCH is doing a terrific job. My position in a foundation is unique. Not many people are sitting in foundations, and my job is in part to envision what could be, and not just worry about how things are. So in thinking about what could be, and that really hearkens to what Peter has said, we need to talk about our outcomes and what we're trying to achieve and then that will guide our activities. And sometimes we're not doing that, I think, with the breadth that I would like to see. One thing I'd like to see happen with MCH is as some people mentioned earlier, the children's bureau. I'd like to see us come back full circle to that, and I mean that in a couple of ways in terms of the functions of MCH. I think one is to speak for children, and the second is to try to help enable other people do their job more effectively for children. Let me separate those.

I loved hearing Dr. Koop speak this morning. I almost said Dr. Spock speak. That would have been a very interesting Freudian slip. And the multiple standing ovations he got, and I turned to one of the people who was sitting next to me and asked, "Do you know the name of the current Surgeon General?" I can't remember. I apologize for that, but we don't have anybody speaking for children in this country. We don't have a voice that stands out like Dr. Koop did, and I think that's why he was getting the applause he was today for what he had done in the past and what he's still doing. His being that spokesperson and I think we in MCH and those affiliated with MCH have that responsibility. And we need to speak for children in the way that he did; not just around health, but around health as the way the World Health Organization defines it. And when you talk about children's health and well-being, the whole child, bring that together, we are handicapped to some extent although the initiative of those you in the audience in overcoming this handicap is phenomenal.

The handicap is that we're funded categorically. And we struggle not only with our own categorical funding, but those of the people we'd like to partner with, to collaborate with, because they have categorical funding too. And that is a terrible barrier. We have just funded a study of primary healthcare in ten other countries, and there's a young researcher and her colleague who are running around the world, thanks to our fund, visiting in other countries. And I keep getting her emails back about how different things are in other places, how that kind of division between medical care and the other things that effect children's health and well-being doesn't exist to the extent that it does in this country. Now, we're broadening our view, you know, there are initiatives now on childcare. Ten years ago we didn't have that kind of focus from MCH, and we do, and it's been a major contribution. There's a burgeoning interest in children's mental health. This is a constantly evolving and responsive field, and I think that's to its credit, but we're still doing it in pieces. And what we have to think about is, "How do we get beyond those pieces?" And these spokespeople--in ways, even if it’s just not what we do, but we find the voice to talk about all these things.

There was a mention this morning that infant mortality rates have ticked up. Well, when I was in public health school, we learned that infant mortality is not a measure of healthcare; it's a measure of social circumstances of the families. It's a reflection of the increasing income disparity in this country, among other things. In public health, we have that responsibility to speak to those things, as well. So even if we can't see exactly how that fits into what we're doing day to day, whether it's making sure children have access to healthcare, making sure we deal with those family issues of violence, substance abuse, and maternal depression that are really pushing lots of children down in their communities. We need to focus on standards better. I'm not opposed to evidence of best practice. We have to articulate those, but not let them dissuade us from looking at the other things. We have to focus on training of ourselves and of our colleagues.

There are an awful lot of things that are not pure MCH, but in fact, if we go back to the children's bureau sense of what our role is about, they are. And so my first admonition for the future and things we need to work is overcoming the categorization, and being spokesman in the absence of a Dr. Koop or a Dr. Spock or other individuals who have the limelight and are really willing to use that for children. Then we have to pick up the slack and do that. Secondly, we have to be able to do as my colleagues have described so well, work to enable other people to do their job well. And in the process we have to--in order to be able to do that, people have to know who we are. And this gets back to the marketing thing that was there. I've been thinking a lot about the linkages between public health in the communities and child healthcare providers in the communities. In many communities, that link is an oxymoron. It's not there. We don't know one another, and we have to start making a little more effort to not making assumptions about that somebody else knows what we do and that we know what somebody else does, and we really have to do the kind of collaboration that Doug outlined in terms of, not just sharing, coming to the shared values, but really spending enough time so that people understand where we're all coming from.

At many of these meetings in the past, and at the MCHIP meetings, you know, at the MCHIP meetings there's that time to go talk to your legislator, and somebody always says, "Well, because they don't even know what Title V is." How can we exist in a world where our major leaders don't know what we're doing? So if we’re going to be effective, then we have to be much more effective in telling people who we are and what we do, and what our goals are and state those goals in the kinds of broad terms that they will understand, and then clarify our role for that. I think because of the confusion, uncertainty, of what public health is, particularly MCH, if you ask a pediatrician what public health is, they start mumbling something about lead screening and immunizations, and that's part of it, but that's not what most of you in this audience are doing. So we need to be finding ways of clarifying for ourselves and for those that we work with so that we can reach out to them. They can't reach out to us, because they don't know what we do. So we have to be reaching out to them, and that's just the way the world is today. And that has to be part of our process, as well.

So my final point then is keep our eyes on the prize. Our prize is not infant mortality; our prize is not any of these categorical things. Our prize is the health and well being of children and that's going to take a broad view, concerted effort and some real visible spokespeople.

GREG ALEXANDER: Thank you, Ed.

GREG ALEXANDER: I know Doug wanted to follow up, but before he does, Duane, I know you have another appointment, do you have a final word for us?

DUANE ALEXANDER: No.

GREG ALEXANDER: Okay. Thank you so much. Doug.

DOUG PATERSON: I wanted to comment that I think part of our job is to be somewhat visionary and try to define what things look like in ten years. One of the things that we have been doing with our Early Comprehensive Child Systems Grant, which, by the way, I think still has an awful lot of potential, but I've also come to learn that it doesn't necessarily mean that all 50 states are going to be successful, because some of that is going to be dependent upon your political environment and where your focus is. I was blessed that this grant came along at a time when we had a new governor who had clearly stated that her top priority was kids and she wanted to create a children's cabinet and do something. So it came at a perfect time because it, sort of, allowed there to be some glue and we could say, "Well, we could do this." And we went out and we talked to the communities. We used the Web and we had community conversations trying to define what are the results that families want, again going back to Mark Freedman's work, and we got 11 of them. And I think that the division would be for a day when we have communities where there is only one system.

There isn't a mental health system, and there isn't a public health system, and there isn’t a medical care system, but there is one system. And when you're born in our county or you come into our county and you first encounter us, you're in our system. And we have a mechanism to share the information with your permission with each other and to do a thorough assessment of how the system can best help support your family and then work with you. And I think that's the vision. And that’s what will bring the shared ownership and the shared responsibility and the collaboration, and we need to start talking that way. I'm very encouraged because when we first had a summit in Michigan and brought some of our communities together, some of them laughed at us and said, "We're already doing this. You guys are the ones that are behind the eight ball." And there are some communities and some leaders with some vision out there that we need to hold up and we need to support, but that's our vision, or at least, my vision--what I would hope our vision would be that we can do in the next ten years.

GREG ALEXANDER: Thank you, Doug.

Well, we've heard from the suits. Now, it's time to go to the one who represents, what I will say is the heart and soul of why we're here: our children and our families. Yes, and I've done this so we could end this session getting back to those fundamentals, so we don't forget those. So Connie, from your perspective, what are the MCH challenges for our families? What are the opportunities for them? What are the opportunities for us to make a difference for them?

CONNI WELLS: Thank you, Greg. Well, in listening to everyone, I think we all know there are a lot of challenges ahead of us. Raising a family is a challenge. How many of you are raising or have raised a family out there? You all know, it's a challenge no matter where you're doing it and how you're doing it; it is a challenge. It's a challenge for the neighborhood, a challenge for the community, a challenge for the city or county that you live in and certainly a challenge for systems development. I think one of the biggest things we need to remember is that raising families is not a program; it's a process. And as we look at the way we're approaching supporting families, we keep supporting programs and often ignoring the process. And we need to watch that closely. I'd like to highlight a couple things that I think are the number one challenges for families and everyone at the table alike, and together we can address those through the opportunities they're going to create.

The number one challenge is the diversity of our families today. Our families are very diverse. Look at the diversity in this room. And it still doesn't represent the complex cultures and diversities that we see across the United States of America . And we need to look forward to how we're going to address those diversities. You look at me here in a pink sweater different than the suits, and you all make assumptions. There's no way you can possibly know what it is that my parents instilled in me in terms of public health and taking care ourselves, what I have put into my children and what my children are putting into their children. And there's no way that you can possibly understand the influences of the neighborhood that I live in which is a little tiny fishing village on the Gulf of Mexico . You can't even imagine what types of priorities that community has.

The biggest day of the year, the day of celebration is not Christmas; it's Little League sign-up day. So the diversity there is very different from community to community. And I think it becomes a challenge for anyone working within the MCH world to protect that diversity, to support the cultures that live within their communities in a way, and still enable them to reach the health goals that they’ve set forth. You know, we realize this so much our state recently encountered many opportunities to reevaluate our capacity to serve families under the worse of circumstances. This came through a series of hurricanes that allowed us to not plan, but actually experience a process. Tweak the process. Experience it again. Tweak the process. Experience it again. And finally, tweak the process, and experience it again. Hopefully not to be done again during the next 58 days that are left in this year's hurricane season. But as our organization went into a small community that was very rural in central Florida where the majority of the people did not speak English, and they were not from this country. We were so stricken with how they struggled and how the system struggled to meet their needs.

How the system works so hard to try to get them simple things like ice, water and shelter. And there were so many things that got in the way. The families didn't understand the language. Just because many of the families were Latino did not mean that they spoke a straight type of Spanish that had been taught at the university that many of these people had learned. They spoke many different dialects. Families were inhibited from coming in and getting help by the soldiers that were there that had guns. I have to say when I drove into the county, I was hit first by the fact that there was nothing green, nothing at all, and there was no bark on the trees. Secondly, I was stricken with Jeeps and soldiers and them riding around, and I thought I had been thrown into a Third World country. So I can imagine if myself was that scared, how much these other people feel. And working with them in their communities, trying to create that link between them and the people that were there to help them. It was a real challenge in building their faith and bridging those gaps.

The number two challenge that we have is family involvement. Linda, you're raising a child with special needs, and you know just as well as I do how crammed our days are. And even if you don't have a child with special needs, how many of you as you were raising your children between the ages of birth and 16 had a lot of extra time? No. And so as we look at what we want families to do to be more involved, and for us to be more involved with them, their time, their capacity, and then their priority, what would you like us to give up? The homework so that we can attend a meeting? Would you like us to sacrifice a therapy so that we can come to participate and volunteer at school or to plan a nutritious meal? I'll tell you, the frozen food aisle looks pretty nice when you're going down through there and you’ve still got, you know, practice to go to, a meeting at school, homework to do, baths to give, and clothes to wash.

You know, I'll give you a typical day of the Justice family. They're a good example. They're fairly low-income, two parents, both working. They have three kids: Jordan who’s eight, A. J. who’s nine, and Cody who’s ten. On a typical day, Dad leaves for work at 6:30 in the morning. By 6:45 , the kids are all up; this isn't new to any of you. They're finishing homework they didn't do the night before, because they were playing on the game. A. J., who has special needs, he's got a serious emotional disturbance, he's taking his medication. We're getting the kid's teeth brushed. She's trying to get the chores done, and if we were to call their house and listen in right then without her knowing it, this is probably what we would hear. We would hear, "Cody, drink the rest of your orange juice. A. J., have you brushed your teeth? Jordan, what was your spelling word you were on? Okay, spell 'share.' Cody, what page are you on? Okay. Start reading there. A. J. get off the table. Okay. Yeah. No. Jordan, you spelled that wrong, it's got an 'e' on the end of it. Try it again. Cody, what page are you--A. J., put the cat down." And the morning goes like that, and that's the good part of the day. And then they drop them off at school, and then after school we've crammed our children's lives with so many things. There's dance, there's football, there's therapy, there's after school, there's friends, there's homework. It is amazing what we have done to the children of today. So when we think about that, even if she wanted to, how are these children's mother supposed to plan a healthy meal, make sure their children are getting exercise, attend a PTA meeting, check their teeth, and assure that they're getting the kind of preventative care. If you ask a mom like that, you ask her when do you take your child to the doctor, "When they're sick, and that's about it."

And so the opportunity for the MCH world and all the providers out there to interact with the family in positive way is clouded and wrapped with an illness and a concerned parent which is really a bad environment for teaching families how to effectively promote the health of their child. The last thing I wanted to talk about is the challenges partnerships. How, as a family, am I supposed to know who, how, when and where to partner with people? I don't always know everyone--this is the first time I've met some of these people at the table and yet, they're outspoken advocates. They're incredible on sources of knowledge as well as funding for people who want to promote and move forward an agenda of healthy children.

Families, as we said many times, don't know what MCH is. We haven't got a clue. Families know what children's medical services is. They don't know what Title V is. They know that they go to the building down on the corner that's next to the Department of Health. They know what the Health Department is most often and many of them will know particular programs within their own school, but again because raising a child is a process not a program, it becomes really difficult to link families to all the different things that they need. And that's where partnerships come in, and they become critical. What kind of opportunities has this created for us? You know, one of the things that my mother taught me and her mother taught her and I'm sure that her mother's mother taught her is that challenges always create an opportunity.

If you look at a challenge only as a challenge; that will be the end of growth. Every challenge is an opportunity, and I think that we know that if there were no waves in our ocean, we would never know how to survive when a storm does come along. And if you don't use a muscle it will eventually go away. Challenges are not a bad thing. Challenges in my world are a good thing, because they do create opportunity. If I didn’t have a daughter who had special healthcare needs 22 years ago, I would never have learned how to stand up in a meeting and advocate for individuals who spoke a different language and whose skin was a different color than mine when they couldn't get to the table. I wouldn't have known how to open those doors. I challenge you and everyone in the room to model cultural competence across the board. And don't look at it as a program. Cultural competency is not a program. Cultural competency is a belief, it's a process that we interweave into everything that we do. And if we can not do that, than we will continue to serve families in the United States of America in silos, and I don’t think that any of us want to do that.

Our second hurricane was a wonderful opportunity for us to learn about that, to do things better. Remember we got hit, and then changed, and then hit and changed. The second time we had a hurricane coming, because it was so difficult for Spanish speaking populations to understand the seriousness of what was about to come upon them, our governor, who speaks fluent Spanish, he stood there and gave the information in Spanish first. And then translated it back into English, which was a wonderful way to tell that population what was about to happen. Build in family involvement at every level. Be a model. All of you--almost all of you raised your hands as having raised children, so you know what the families are up against. So be a good model for these families. You know, the Justice family as they interact with the multiple organizations that they work with, they don't always know what's going on. And they're going to have to have people model that for them. Emulate the organization that they're going to have and enable family involvement at every level. We need to keep kids as the focus.

A wonderful example of how what you're doing is actually teaching children and teaching children to correct adults. When we were recently on a vacation to Michigan , not to slam your wonderful state, which I was born and raised in. My grandchildren who are ten, nine, eight and seven, the older ones, were walking at the county fair that we were at, and they all stopped dead in their tracks and they looked forward, and they went, "Gasp." And you could see them look in the sky as they thought a bolt of lightening was about to fall upon the people in front of them who were carrying cigarettes and smoking openly in public. They were appalled. My grandchildren have never seen such a thing. And one of my granddaughters said, "Oh, I'm telling Jeb." Creating those partnerships, here we are, a wonderful opportunity for the next couple of days for us to work together to promote the health and safety of American's families in crisis. You know, we came together when there were hurricanes, and I saw help from Ohio , Iowa , Missouri , Pennsylvania , and every state you can possibly imagine.

I'm here to challenge you that we have a healthcare crisis in America that's as important as any individual storm. If you want me to give it a name, I'll give it a name. Let's call it Isaac. Isaac is a child whose family recently contacted us. He's a newborn child in Florida who does not have special needs, but was born into a very complicated family situation. Isaac is a crisis as is every other child who is born the same year as him and will graduate in the year 2022. That should be our priority. We need to come together as if this were a hurricane and figure out how it is we're going to meet the needs of he and his classmates. You know, I liked the cartoon of the cat. Remember the cat that was, kind of, thinking outside of the box, the box being the litter box? I'm not so sure we shouldn’t all wear little cats on our suits or sweaters, and remember that if you're going to be a cat and think outside the box, things for a while may seem a little bit messy. And you may get in just a little bit of trouble for thinking outside the box, but you know eventually, someone's going to get the idea and come through and clean the old box out, and make a little bit of room so that we can start putting things in their proper place, and get to where we need to go for our families.

GREG ALEXANDER: Full of comments. We have a few minutes left, and that gives us an opportunity to have you join our panel and present some issues. But in fact, I'm going to turn to our panel and ask them one last question, and I'm open to any of you using these microphones. How can we optimize the time we have together at this meeting to do something to improve the future right now. We're here for three days. It's quite an important event, all of us. What can we do?

CONNI WELLS: May I go first on that one?

GREG ALEXANDER: Yes. You may.

CONNI WELLS: Thank you. You know, I think we need to look around the room and know that every individual in this room has something to contribute to the box. And no one in this room is any more important than the other, and when we start approaching the next couple of days with that in mind knowing that you have something I have to have in order to get to where we need to go to meet our vision. Jennifer from Family Voices has something to offer to everyone in this room because she carries a link and a key to the voice of families. And Tawara Goode who is here from the Georgetown University Center on Cultural Competence has something incredible to offer to each and every one of use in learning how to master working with diverse families. So I think that the recognition and the respect of what one another has to contribute is critical to making the next couple of days successful.

GREG ALEXANDER: I'm going to follow up by--I had a student ask me not too long ago, if I had to reduce down to one word what my vision was for MCH, what would it be? And it was so clear to me; it's just simply leadership. And it affects every one of us. It's something every one of us needs to bring to this meeting and everything we do in this field. Go ahead, Peter.

PETER MORRIS: Well, to borrow from some copyrighted material. If we can keep the end in mind, and I would simply say we might want to raise our line of sight, another copyrighted statement, to say that we need to not only think about the kids, but to think about families. I do think this is who comes to our services--and we need to make it easier for them. But I’ll offer something else, I see Milt Kotelchuck sitting out there, and I think it was Milt Kotelchuck and Julius Ridgemond who once said that public policy is made out of data, strategy and will. I don’t think there's any lack of will in this room. I do think there's a role in advocacy in increasing the will within our communities; don't get me wrong. From a data point of view, I love hearing from my colleagues here about the things we need to know, but I think sometimes we get too embroiled in that data, whether it will be a process outcome or an indicator or do you think we're measuring it--I think what we may want to be doing is raising our line of sight and wondering what strategies it is we can employ in our communities, in our states, in our organizations that actually keep that end in mind, and I think that's doable in a three day period to come home inspired to be able to raise our will to get it done.

DOUG PATERSON: I would challenge you to meet five new people that you don't know, and that doesn't mean introduce yourself. That means spend a little time and get to know them and find out what they would do. And I would challenge you to take back three ideas, at least three good ideas that have some relevance to what you do that you can use at the state. That's sort of what I try to do when I go to a conference. If somebody says, "Was it a good one?" If I was able to do those two things, then at least I accomplished some things and I’ve shared that with other people. And I think if we did at least that, all of us multiplied by 1000 people here; that would be progress. Let me share a story with you, since we've got professors up here. The relevance has to do with research design. The professor asked his students in Stein's class his first day what he thought the most significant invention that had ever been made in the world was. And they thought a minute and the first one said, "Well, I think it probably had to be the telephone, because it just opened up the communication, and now computers over the telephone network, and everything. It has to have been the most significant design." Another one said, "I think it had to be the airplane and the jet engine because you can get anywhere in the world that you want right now." And the third one said, "Well, I think it's the thermos bottle." And the professor said, "The thermos bottle? All that does is keep hot things hot and cold things cold." And the guy says, "Yeah. But how does it know the difference?"

GREG ALEXANDER: Ed? Last words.

ED SCHOR: Hard to follow that. I guess I'll go back to the theme that I had. When Connie asked how many people in the audience had families--raised kids was the question and most everybody raised their hand. You need to remember that only less than 25 percent of the households in the United States have children. And so 75 percent of households in this country do not necessarily share the agenda that that other 25 percent does, and even that other 25 percent isn't so solid around children's issues. So we have a long way to go, and just because you're going to learn a lot from each other and I hope you're going to network with one another. But remember that this is a cocoon and there's a whole big world out there who doesn't know what we do or what we believe. And part of our mission is to make sure they do.

GREG ALEXANDER: I want to thank my panelists. They worked really hard. And I appreciate what they said. I want to than you. Before you--don't leave. There are some announcements right after me. But I thank you all so very much. I think there's still much to do in this field. There always will be, but we have always risen to those challenges and turned them into great opportunities. Thank you again.