HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Challenges of the Next Decade that the MCH Community is Uniquely Positioned to Meet

LISBETH SCHORR: Well, I’m delighted to be here with you today because it seems to me that people in this room play a unique role in our national life. Today and probably even more so tomorrow as the problems that we address become ever more complex and your role as bridge builders and connectors and infrastructure builders become ever more important. The outcomes that we’re after and I think we pretty much share our purposes. A nation of mothers and fathers and children who are healthy and thriving and ultimately contributing to society, to a society they feel valued by and connected to. Those outcomes are not going to be achieved one program at a time or even one system at a time. So, you’re charged to cross systems, to put together programs, it seems to me is absolutely crucial. You may not be unique in understanding that but you may be unique in working under the auspices of public agencies that actually have the mandates to put together what works rather than slicing everything into ever smaller and more isolated pieces, pieces that may make sense to administrators during organization charts but that don’t match the messy needs of real children and families.

Now just on a personal note, Dr. van Dyck told you quite a bit about me. He did not tell you about any of the advanced degrees I have, but that’s only because I don’t have any. I graduated from college at a time when we didn’t know that you wouldn’t get anywhere without an advanced degree and so because I never did any graduate work and people ask me, so what is your specialty anyway, I had to develop a specialty of my own. And my specialty is in what works and what we can learn from past successes. It’s really, it turns out to be a useful specialty. And the first book I wrote, “Within Our Reach” was about programs that work. It celebrated some 25 programs that had achieved documentable successes and although not all of those successes were documented in the evaluation literature, I took a somewhat broader view of what it means to document success. Martin Gary who was the Assistant Secretary of Planning and Evaluation, and it was HEW at that time, said, Lee found all those wonderful programs because she never went to the evaluation literature. That’s almost correct. The, one of the astounding things about what happened after that book was published and I told these stories of these wonderful programs and also identified many of the commonalities they had, but five years after the book came out, half of those programs were no long in existence and very few were being built upon. And that seemed to me really puzzling and I asked why is that? And wrote my second book about basically the systems context, the funding context, the regulatory context that made it so hard for good programs to survive.

I draw, in preparing the talk that I’m giving to you today, I drew on the materials in both of those books. I also drawn on my more recent work, “Pathways,” the pathways mapping initiative, which has put together an extensive array of information about what works, especially in the early childhood and prenatal period. I draw also on the very recent work of Amy Fine and Rachel Mayer for the Commonwealth Fund, who have been looking at effective pediatric care linkages to community services. And I draw on Jane Knitzer’s for the National Center for the Children in Poverty. Judy Langford’s for the Center on Study of Social Policies and the Casey Foundation. And also the writings of Larry Green, the Public Health Educator whom some of you may know, who is now at the University of California at San Francisco. In Larry Green’s book, “Health Promotion Planning,” he tells the story of how efforts to reduce cigarette smoking became one of the most successful public health stories ever. He says the precipitous decline of smoking in this country came only after the field shifted from seeking a magic bullet among the circumscribed but proven individualized interventions to understanding much more comprehensive and complex community and population based interventions that were harder to implement, harder to measure, but ultimately proved vastly more effective.

Another success, the reduction in teen pregnancy, tells a very similar story. As you’re all aware, between 1991 and 2002 the national birth rate declined by 30 percent. That’s significant. It happened yes, because new and more convenient forms of family planning became available and accessible. But it was also the result of changing norms that were the product of highly effective and very intentional focus media campaigns. Is the result of community based programs like Plain Talk, community based and school based efforts to inform and educate youngsters and to provide them with a comprehensive mix of academic supports, art supports, healthcare, and service work.

Now, we may not have those kinds of success stories when it comes to low birth weight, substance abuse, child abuse and neglect and school failure. But my guess is that when we begin to document significant reductions in those areas, the story is going to be the same. There will not be a single magic bullet, but a complex array of synergistic interventions that will combine to produce the results that we seek. And that, it seems to me, is why it’s so important that your orientation is as broad as it is, by being willing to adopt a comprehensive view of your work. The, just taking the comprehensive view is, of course, not enough. But it seems to me there are a lot of lessons from past successes that can inform that comprehensive view and guide your work of the next decade. I think we’ve learned so many important lessons that we can draw at least, I’ve tried to draw four conclusions. First, we have to be clear about the purposes of our work and we have to be able to document that we’re achieving those purposes. Second, we have to get better at determining what works and building a knowledge base of promising and effective actions and strategies. Third, we have to forge new partnerships, as you’re always doing and sustain them. And fourth, I think that leaders in Maternal and Child Health have a key role in developing the capacity to assure that children and families are connected to the services and supports they need and that programs and systems work together to achieve common purposes.

I want to talk about each of these four conclusions in turn. First; that we have to clear about the purposes of our work and to be able to document that we’re achieving those purposes. Once we accept that it’s futile to search for a single silver bullet to produce results, an outcomes orientation is a useful frame for working broadly across disciplinary domains and helping systems. It leads to a problem solving mindset. A focus on outcomes clarifies how often the best results come from an effective implementation of a combination of several promising interventions that in isolation would have little effect, a focus on results and an agreement on results means asking how are kids and families doing? Does the neighborhood feel safer? Are kids and families actually thriving as a result of the interventions that we have put in place? It becomes a way of taming bureaucracies, of getting away from only assessing how well you’re doing by whether people are complying with detailed rules. And it’s a way of overcoming the climate in which everybody is so eager to eliminate the possibility that public servants will do anything wrong, that legislators and administrators tie the hands of frontline staff and make it virtually impossible for them to do anything right. A clear focus on results also drives both funders and program people to think more realistically about the connections between investments and outcomes and reduces some of the long-standing confusion between the means and ends of social interventions.

I was once taken around a Middle Western city by somebody who had, who was heading up a community coalition and he told me, “We are getting such extraordinary results.” And I said, “oh, tell me.” And he said, “We have 14 agencies coming to the table monthly to work together.” And I said, “That’s not how I think about results.” And as we talked it became clear that it was so hard to get those 14 agencies to the table to work together, that they had lost track of the purpose of getting the agencies to work together. And I think that happens, that happens a lot, that there’s a constant temptation to fall back on process measures as evidence of progress. In the scramble for evidence, process measures become substitutes for outcome measures because they provide evidence that something is happening. And it seems to me as we try to push more and more to have this conversation about results, it, that new conversation promises or threatens in the eyes of some, to end a conspiracy of silence between funders and program people, by exposing the sham of asking service providers, educators, and community organizations to accomplish massive tasks with wholly inadequate tools and resources.

Now, I understand that what I’m talking about, especially the part about documenting results in an outcomes based way, it is complicated and it’s hard when the users of our pathway mapping materials asked us to identify which actions led to improvements and which specific indicators? We found we couldn’t do it. We have an indicator at school entry that children can follow directions. Well, is that one impacted most by quality healthcare, by quality childcare, by parenting that is responsive and cognitively stimulating? We find it’s really quite impossible to disentangle physical health from social and emotional outcomes. Both because you can’t separate the needed interventions and services and supports to that get you there and because the outcomes themselves are so intertwined. Now, that’s something that makes our lives complicated but it’s something that we should be celebrating, that we don’t have to choose. Like, in Head Start, should Head Start be a reading program or should Head Start promote social and emotional competence. Well, it turns out that if you don’t provide the kind of support to parents and to kids that strengthens social and emotional competence, they’re also not going to learn to read. They’re not going to read just with flashcards and they’re not going to become healthy, only with immunizations. And that’s why my pitch is permeated by not choosing one or another but by saying, by understanding that we promote health as we promote social and emotional development. We promote social and emotional development as we promote health.

Now, although we do a lot of preaching at Pathways about the importance of documenting measurable results, I have to confess to you, we have had a great difficulty in our work with communities to identify the indicators that will allow them to document progress to outcomes. And I’d like to think that some of the data work that many of you are engaged in will ultimately make it easier, especially to document progress among the children and families in the neighborhoods that are not, the children and families who are not participants in particular programs. You won’t be surprised to hear that in the course of our indicators work, we found significant gaps between what communities want for children and families and what can be measured. We found confusion about which are the most reliable indicators of progress, and we’ve had a lot of difficulty in extracting usable data from the patchwork of local, state, and federal systems for the populations, the intentional community based efforts are trying to effect. But we urge community people to do the best they can with the indicators they’ve got, because trying hard is simply no longer good enough. We have to show results.

Secondly, the second conclusion I want to talk about is that we have to get better at determining what works, and building a knowledge base of promising and effective actions and strategies. Now, I talk about promising and effective actions and strategies rather than the simpler term, best practices, which is less cumbersome and more convenient. But I do think that best practices obscures the fact that it applies more accurately to clinical practice than to social change. Well, the human organism is relatively consistent in its biological functions. Human communities, organization, and social behaviors, are far more variable, making identified best practices less certain of producing reliable outcomes in varying context. Of course, that doesn’t mean that we can’t learn from what has worked in one place to inform actions in another. It ‘s just that I think we have to be very careful about thinking of spreading circumscribed units of best practices in any mechanistic way.

Now, what we’ve, so much of what we’ve learned about ways to improve the life chances of mothers and children and especially those who live in tough neighborhoods or who otherwise have the odds arrayed against them, much of the prevailing information comes in small, isolated, disjointed pieces. Often it arrives too late, fails to identify the subtle factors that really made the intervention work and is derived from a severely limited set of interventions, just those that have been elegantly evaluated. The innovations that will make a dent in apparently intractable problems, so often involve complex relationships across multiple causes and affects that require connections among efforts aimed at physical and mental health, housing quality and affordability, family stress, availability of employment, and family income. And here I think we need a very different approach to understanding what works. It’s almost impossible to assess the effectiveness of these connections using traditional, experimental methods, especially those involving random assignment, because the circumstances vary so significantly across communities and states that just knowing that something worked under laboratory situations where the implementers had complete control over who was in and who was out and gave the experimentals the drug, the intervention and the controls for the placebo.

That analogy just doesn’t work in the complex social interventions that we’re all involved in. And it was in response to that understanding that our pathways mapping initiative has developed an approach to understanding what works that allows us to assemble a broader and deeper pool of knowledge than is typically available. We do this through a process that we call mental mapping, which is similar to the consensus conferences convened by the national institutes of health. They’re both attempts to move beyond reliance on isolated pieces of evidence and a narrow range of interventions. And instead, to apply reasonable judgments and plausible interpretations to a preponderance of evidence called from accumulated experience and from theory as well as from research. And the answers that surface in that process do in turn, indeed turn out to be different from the answers one comes up with by looking just at the formal research. For example, the school readiness mental mapping group pointed out the social isolation of families with infants and young children that emerges from both research and practice as a major risk factor for rotten outcomes. But the research that has assessed interventions that have sought to reduce isolation, family support centers, home visiting, et cetera, has typically not found improved outcomes for either parents or children. Efforts to reduce social isolation therefore very often don’t appear on the screen when we look for proven interventions raise rates of school readiness. But what if the reason for that is that the effect, efforts to intervene that we’ve measured have been too circumscribed.

Until recently we failed to use the disappointing evaluation results to generate new hypothesis. We failed to deal with the possibility that a high proportion of mothers didn’t engage with home visitors because they were depressed or because they were living in the midst of violence. We didn’t deal with the possibility that the children of these depressed mothers needed a different kind of intervention if they were not to lose ground. I suspect that our evaluation conventions together with our categorical funding conventions discourages us from looking to see what would happen if we were to put together a new set of interventions tailored to respond to the barriers we uncovered in our efforts to help. We’re now in a position to create much more actionable knowledge and that’s what we’ve tried to do in, in our pathways project. To make it possible for each local initiative to start with something more than a blank slate, to encourage the preeminence of local decision-making, local initiative, imagination and adaptation. To not prescribe solutions, but at the same time not dismissing the existence of centrally available expert knowledge.

My third conclusion is that we have to forge new partnerships and sustain them, something that you’re already very actively doing. I think there is, first of all, the MCH role in forging partnerships to expand the circle of those who care about these issues and therefore support your work. Just to give you one example of sort of going outside your usual allies, I found a whole new audience of people interested in eliminating racial disparities and birth outcomes in children ready for school and in the transition from adolescence to young adulthood. Among those who take seriously the Supreme Court’s decision in the affirmative action case recently, just as Sandra Day O’Connor’s decision envisioned that 25 years from now racial preferences in higher education will no longer be necessary. Clearly that’s a realistic expectation only if the nation acts promptly to put in place the measures that would eliminate or substantially reduce racial disparities that occur in the pipeline between birth and university admission.

Then there are the partnerships to leverage your ability to change outcomes since no one system can do it alone. Health services, housing, childcare, drug treatment, mental health, family support, income support, all play their part and have to be connected in some way to be most effective. All around the country people tell each other, it takes more than personal health services to keep children and families healthy, more than child welfare services to keep children safe. More than police to keep neighborhoods free of violence, more than family support services to strengthen families, and more than good preschool programs to get children ready for school. And, yet, when it comes to planning interventions, typically people act as though each system could achieve its objective on its own, even as though each individual program could in isolation achieve valued outcomes on its own.

When, in our pathways work, we had done the first construct of a pathway to school readiness, we asked Jane Knitzer at the National Center for the Children in Poverty to look at it and tell us, what you have to do differently if you wanted to reach the highest risk children and families? And we were very surprised when we got back her paper and it didn’t say, here are the new programs you need. It was all about here are the connections that you need to make so that you can reach those highest risk kids and families.

You’ll be hearing later this conference we’ve already heard this morning about exciting new partnerships to increase school readiness, strengthen child abuse prevention, and the commitment to adolescent health, all of which there are sessions about at this conference. There’s also increasing interest around the country, which some of you may have come across in partnerships that use childcare settings, not only to identify families whose protective factors need strengthening to prevent child abuse and to identify maternal depressions as well as to provide case management from the base of the childcare center to assure that these families get the services they need.

A survey of some of the most exciting partnerships that are now underway makes me realize that under the radar, we may be in the late John Gardner’s words, in the midst of writing a new chapter in the tumultuous American story of domestic problems or solving. Here’s just a sample to give you the flavor of all the partnering and boundary crossing that is currently going on, some of which I know you are involved in that you have in fact caused. I’m sure that most of you could identify more. There’s Kids Get Care in Seattle, partnership of the Seattle and King County Department of Public Health and the local practitioner community through which community health educators and case managers work with families and staff of community agencies to assure that children, regardless of insurance status, are attached to a medical home and receive early integrated preventive physical, oral, and developmental health services. There’s Healthy Steps for Young Children, which I know you all know emphasizing close relationship between healthcare professionals and mothers and fathers and which also extends pediatric practice out into the community. There’s the Boston Medical Center’s Department of Pediatrics, which recognizes and acts on the fact that medical care doesn’t mean just caring for illnesses or injuries but treating the whole child and family, and provides onsite assistance to families with health related needs through the family advocacy program, through project health, through reach out and read. There’s the Harlem Children’s Zone, which found that 26 percent of Harlem children ages 0 to 12 have asthma over four times the national average in there, in the 24 blocks that they are concentrating on. And working with Harlem Hospital, Columbia University, the Harlem Health Promotion Center, and the New York City Department of Health. The Harlem Children’s Zone now screens all children within the zone offers home visits to conduct individual assessments and provides information services and medical support to families who are dealing with asthma. The last example of these partnerships, the county of San Diego Health and Human Services Agency found that the health needs of children in foster care were not being met and partnered with the local child welfare agency to make sure that this high risk group of children would receive timely health examinations and follow up care. Public Health nurses provided education to social workers, probation officers, juvenile court attorneys and judges, and physicians about the special health needs of children in foster care.

Now, let no one think that this exciting of boundary crossing partnerships just happens. Connecting across systems requires sturdy relationships that have to be supported by funding, by hard work, and often by changes in culture. Formal agreements are necessary but are not enough. I couldn’t help thinking about an experience I had, let's see, it has to be now 40 years ago when I was working in the poverty program. And we were just getting Neighborhood Health Centers started and we were aware that exactly what we were trying to do in neighborhood Health Centers, was what the children in youth centers under Title V were trying to do in those same communities. And we thought, shouldn’t they be working together? And so we worked it out so that we finally had a summit meeting between Sergeant Shriver, the Director of OEO and John Garner who was then secretary of HEW. And we had drafted a memorandum of understanding or precisely how Neighborhood Health Centers and children in youth centers would be working together. And it was gorgeous and we got it out in a very glitzy form and distributed widely. And, of course, nothing happened. Absolutely nothing happened. And it was a great lesson to me about if all you do is a top down memorandum of understanding you may as well not go to the trouble. However, if, if we had understood about the local and state relationships that would further that collaborative work and if we had been working with people like yourselves to bring that about, I think that would have been very, very different.

The fourth and last point I want to make is about the key role of MCH leaders in developing the capacity especially at the local level, to assure that children and families are connected to the services and supports they need. And that programs and systems actually do work together to achieve common purposes. We have exemplary programs to show what can happen when we look systematically at what’s there and what’s missing. In South Carolina, local public health nurses are actually deployed not just within the Health Department but to Pediatric practices. In San Francisco public nurse, public health nurse consultants work with the staff of childcare centers. In San Diego First Five money has gone to the Children’s Hospital for developmental self-screening using parent classes and one-on-one parent professional sessions to allow parents to self identify their needs for help.

But, of course, exemplary programs are not enough. We know that effective programs are typically characterized by flexibility, responsiveness to a wide and sometimes messy range of issues, frontline discretion, the ability to see children in the context of their families and families in the context of their neighborhood. And a high priority placed on the creation of respectful trusting relationships. Many of the systems on which high-risk children and families depend seem quite oblivious to these subtleties. That’s why the best people on the frontlines are fighting everyday to do what then know works against the pressures designed to move them in exactly the opposite direction. I spoke a couple of years ago in Charlotte, North Carolina and talked about these attributes of effective programs, about the flexibility, the relationship intensiveness and so on and got a letter when I got back from the director of a Community Health Center there and she said, you know? Those characteristics that you talk about, they are exactly what we in our Community Health Center do everyday and they are exactly the opposite of what the hospital under whose auspices we operate tries to get us to do.

So we have people swimming up stream and telling anybody who will listen about their constant struggle to bend the rules, to sometimes break the rules, but they can do that and they can do it stealth, well, they’re running pilot programs that remain small and operate at the margins. But when they attempt to scale up, especially as they harness public programs and public funds, they’re confronted by rules and regulations and funding realities that end up destroying or deluding the very attributes that made the original model successful. If relationships are a key ingredient of effectiveness, but funding realities don’t allow staff to spend the time it takes to create and cultivate those relationships, then we shouldn’t be surprised if model programs get terrific results only when they’re operating in the hot house. Same thing is if funding does not support the critical elements of what you’re doing.

There was a study, this is a very old study, but I suspect if it were done again, the same, the same results would come out of it. It was a study of Rural Health Centers and which ones survived and which ones went under. And it turned out that the Rural Health Centers that survived were providing a much higher proportion of lab tests, EKGs and complicated technological diagnostic tests. The ones that went under were the ones that were doing outreach and providing social support. Well, that was because the outreach and the social support simply doesn’t get reimbursed. I mean, it’s not a big mystery. It’s just that this is something that we have to recognize and do something about. Unless we’re prepared to rely forever on wizards who are some combination of a Mother Teresa, a Machiavelli, and a Certified Public Accountant, an honest Certified Public Accountant I should say, we have to pay more attention to the policy and systems and funding context. By making that context to more hospitable to what works, people with their hands on the levers of systems change could assure that more talented people and more mobilized communities could act on what we know about improving outcomes for large populations of children and families. And the people in this room are, it seems to me, in the best possible position to create both the horizontal and vertical alliances that can partner in the hard work of making the policy funding and systems context hospitable to what works. But it won’t be enough to strengthen the links between program and people and policy people, although that’s essential. It’s my impression that in many places, while there are already efforts to move from fabulous demonstrations at the local level to worrying about reaching all the children and families who need to be connected to high quality services, it’s also true that in many more places, we lack the local entities that are capable of applying a public health population based, place based mindset to an assessment of what we have, what we need, and what needs to be done about it.

The State Early Childhood Comprehensive Systems Grants are a great example of getting people to think in population and place base terms. But how do we make sure that all the functions that need to be performed, that all the services and supports that have to be available and identified are indeed available, accessible, and of high quality in local communities. Can Title V support a more systematic approach across agencies, asking whether kids and mothers are getting what they need? Can we rethink the boundaries and the connections between public health and private providers, between providers of personal healthcare and public health services, and among the health childcare and child welfare systems? MCH has this capacity at the state level and they have the mandate. Is it now possible to develop the structures that will have the capacity to work with people at the local level to do what nobody is doing, except in isolated instances.

To monitor the adequacy of services and supports in relation to achieving outcomes and to act or encourage action to fill the identified gaps, to act to assure that all partners do what it takes to achieve the specified outcomes. To assure connections among programs and systems and between families and needed services and supports, before formal systems and informal supports, among Pediatricians, childcare programs, child welfare and public health. And to spread the norms that support achieving outcomes, such as that all births are wanted, that parents are ready for responsibilities of parenting before they become parents. This line of thinking may reflect some naivety on my part about the constraints under which you operate. But I can tell you that I wouldn’t have ventured into this territory were I not struck so frequently as I go around the country, as I listen to people who are trying to make their neighborhoods livable and their services more responsive. I’m so struck by how much we need the leadership to get to work on this missing, monitoring, over arching, sorry about that, umbrella peace that could provide the oversight and build on the splendid demonstrations that are now underway, but make sure that they reach into every community and to every corner of every community.

In closing let me just say that I think that we are meeting at a time of renewed urgency around the fate of those who are totally disconnected from America’s prosperity. I think there’s also a new sense of possibility, in part because we have such a rich array of knowledge about what works. As we struggle to make our institutions, our systems, and our neighborhoods more supportive of healthy life and growth. I salute you for the contributions you’re making to building in Robert Kennedy’s words, the communities where children can play and adults work together and join in the pleasures and responsibilities of the place where they live. I salute you for your efforts to reconnect the thousand invisible strands of common experience and purpose, affection and respect that tie us to our fellow in which will ultimately make America more just. We may not be able to count on heroic figures to mobilize us to act. But perhaps we can be mobilized on behalf of a shared heroic idea. The idea that we’re all in this together, that we have to share the burdens and pool our rich resources, that we cannot allow the richest country in the world to declare bankruptcy in its civic life. Whether we’re motivated by a fear of what happens what a society inequities become so start that it splits apart or by a sense of social justice. We have to act on what we now know so that every family can live in safety, comfort, and stability. And that all our children can grow up with a realistic stake in the American dream, and I wish you strength in your efforts toward that end. Thank you.

CASSIE LAUVER: Thank you very much for an inspiring lecture. This is certainly the choir that you’re talking to and I think that the principles that you talk about are all things that we know, but to focus and refocus on what those are I think are incredibly important for us, as well as also learning that it is possible to create your own advanced degree, which is something that I’ll be thinking about very seriously. She’s gracious enough; Lee’s gracious enough to stay for a few questions or comments. Again we have, microphones around the floor, so do we have any questions or comments that you would like to ask at this point.

KAY JOHNSON: Thank you so much for your wonderful words. You know, we, I was going to say this when I started talking later, but we stand on the shoulders of wonderful leaders such as yourself and, and people who continue to set out a vision and a challenge and hope for all of us in our work. Is there a, something that you reflect on that sort of, you know, in terms of cycles of growth and learning? You mentioned it a little bit but maybe a little more about cycles of progress.

MS. LISBETH SCHORR: I thought I was standing on your shoulders, Kay. I do think that there are cycles and that we’re not in complete control of them. And we don’t even, you know, there are said to be cycles that go in 30 years, political cycles. I think our relationship to these cycles of when it’s possible to really make a great leap forward. Our role is to be ready. We, I think we can also contribute something to a willingness to do a lot better, not just a little bit better. And I think that by documenting that we are actually reached, achieving the results that the public values. I think we contribute to restoring faith in the possibility that government can do it right, and that our partner, that partnerships with government are productive and useful. In terms that people recognize as being really important. So I think to first of all contribute to the idea that we know what we’re doing because we are achieving results, plus being ready to, when there is a greater public will, to take advantage of public support to make more than small incremental and pilot steps. I think those are two things that we really have to keep in mind, so that we can ride the waves of the cycles as they occur.

CASSIE LAUVER: Chris.

CHRIS KOSS: Sure. Chris Koss from New York State. In your work on what works, how do you deal with the questions, how well does it work? At what cost? And is it worth investing in?

MS. LISBETH SCHORR: We deal with it by thinking about it all the time and knowing how very complicated that aspect of the work is. If you, if you go to our website www.pathwaystooutcomes.org you will find that we haven’t done a very good job of answering that question. What is on the website is a, if I do say so myself, a marvelous and rich array of everything that contributes to the outcomes, the most well developed. One of our pathways is the outcome of school readiness. And you see what, what can be done in the health area. What can be done in the, in improving the social cognitive environments of children both at home and in childcare and in improving the neighborhood context, in which children live. We are working right now on the question of what are, among all of these things that contribute, how do you choose those that are most effective, that are most cost effective, and that you can get the most short term and long term results from. And it’s so much harder to do that, I guess, that’s why you asked the question, because you know how hard it is to do. It’s so much harder to do that than to identify the elements that work. We’re now in the process of developing a pathway to the successful transition to young adulthood and there we are starting, not by saying what are all the things that contribute to that outcome, but what, how can we be most strategic in achieving that outcome, which is a much harder question. And, uh, I think that as we put together information about what works, we have to very, very aware of that dosage matters, the implementation matters, that the populations that on which the demonstration programs have been tried could be very different from the ones to which the replication is applied and we have to be very aware of, of those dimensions of what works in order to be able to act strategically. So you’re right. It’s a really important question.

CASSIE LAUVER: Can we take one last question here David?

DAVID SHORE: David Shore, no relation unfortunately, from Ohio. I’m not sure works, works, if I think about a recent experience in my state, our biggest success in the last year or two has been an increase in funding for Children with Special Healthcare Needs in the face of declining state budgets. That was brought about despite the excellent work of the, within the program in presenting all sorts of arguments, but really by voices of parents. Similarly my left-brain Public Health psyche says, data really is convincing and yet nobody is interested in our data it seems to me, so how do you know what works, works? In other words logical evaluations of various kinds and bringing that information forward, can that really change policy or do we really need to focus on advocacy as a fundamental skill set that we all need to know and practice in, in public health, particularly in maternal and child health?

MS. LISBETH SCHORR: I wouldn’t set those up as alternatives between advocacy and rational planning. I think there are a lot of advocates that advocate very thoughtfully in having analyzed the data. Recently when the mayor of Baltimore announced that he was going to reduce the number of kids that arrived at school not ready for school, reduce the unready kids by half. I talked to the staff person who was advising him from whom I had gotten an email about a year before saying that our pathway to school readiness was just the best thing she’d ever seen. So I called her up in great excitement and I said, and so what are you doing to get started. And she said, “We’re getting backpacks with our logo for all entering Kindergartners.” And I said, uh huh, tell me, how, how does that sort of fit in your strategy. And she said, well listen, we had a corporation that offered us those backpacks. And I said to myself, you know, how can I say to her, you should have said no to the backpacks and gone back to the pathway and seen that that was not the first thing that you should be spending your money on. But it wasn’t her money and you have, so I think, I keep thinking about these backpacks as the symbol of something that you have to understand people are going to do because they have to be opportunistic. You know, what other tangible symptom of their being in business could they have had so quickly if they had followed our pathway. Probably none. And yet I’m working with those people to say, okay, now you’ve got the backpacks.

Now, lets go back and look at what might be the next thing that you would do that would have a closer connection to the outcomes you’re trying to achieve. So I think, we work with a lot of advocates and try to get them to do their advocacy with the support of a very rational analysis and logical progression. So, I think we can’t get any of this done without advocacy. However, I think it takes a lot of work, and it takes a lot of, we’re finding that people can’t use our pathways sort of in the abstract, that you can’t just put it there and say these are the steps you should be taking. There has to be an interaction between well, we can get backpacks and we can get this and we can get this and how can we relate that to what it is that we know will make a deeper and more long run difference. It’s a really, all of these, all of your questions, I think, represent how deeply you are thinking and how deeply you are involved in these issues and struggling with them and I hope that our struggles and your struggles can combine to make us work more effectively.