Subscribe
Share
Share
Embed
Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Podicy. I'm your host, Rob Lott. Friends, it's another one of A Health Podicy's very special episodes. That's because although we typically feature the authors of some of the most important recent health affairs articles, we also set aside about one episode a month to go a little farther afield, to sit down with various leading voices in health, health care, and health policy. Today, it's doctor Thomas Dobbs, dean of the John D.
Rob Lott:Bauer School of Population Health at the University of Mississippi Medical Center. Doctor. Dobbs is an internal medicine physician with expertise in infectious disease and epidemiology. He spent decades treating patients and caring for communities, including many of those living with HIV during the nineties and early two thousands, periods of incredible transformation in both the science and capacity underpinning our systems related to HIV and AIDS. More recently, doctor Dobbs served as Mississippi State Health Officer, leading the state's Department of Health, including its response to the COVID nineteen pandemic.
Rob Lott:In 2022, he returned to academia at UMMC in Jackson, Mississippi. And we're thrilled to have him here today. Doctor. Thomas Dobbs, welcome to A Health Odyssey.
Thomas Dobbs:Wonderful, I appreciate y'all having me.
Rob Lott:So let's just jump in. I'm hoping maybe we can let our listeners get a little bit of a sense of your work and career over the years. Tell us a little bit, where are you from? Where'd you grow up? How'd you get into this business?
Thomas Dobbs:So I'm initially from North Alabama. I was born in a small town in Northwest Alabama called Haleyville that is of nestled up in sort of near the Sipsey Wilderness, really beautiful part of the state. Then I went to college at Emory in Atlanta and that was really sort of a transformative time, I think, for a lot of people. And then ended up going to medical school at the University of Alabama in Birmingham.
Rob Lott:Okay, so when did you first think about pursuing a career in medicine?
Thomas Dobbs:Doctor. College, I always thought I was going to be a theoretical physicist. And so that's what I studied as an undergraduate. But then, I had a lot of health exposures, did spend some summers doing, different work. Did some, I spent some time in South And Central America and got to see sort of the situations there, spent some time in the hospital and surgery and had a good exposure to the health environment and then decided, you know, instead of doing or trying to do physics, I went into medicine.
Rob Lott:Do you miss the physics? Do you, dabble in theoretical physics from time
Thomas Dobbs:to Heavens no. But I do, you know, I do read like, you know, news around, you know, exciting findings and, you know, you know, just nerdy stuff like that.
Rob Lott:Cool. Well, tell us a little bit about your early years as a practicing physician in infectious disease. Where were you practicing and what was your focus at that point?
Thomas Dobbs:Through training, I realized pretty early that I was interested in sort of a more population based perspective of health. And I think, when you're in medical school and you're idealistic and then you sort of get into the hospitals and you see that you're really taking care of people at the end stage manifestations of the disease, right? And understanding that a lot of what we spend our healthcare dollar on in The United States is really trying to manage people who have severe disease that could have been prevented. And whether it's like in the infectious disease realm or the chronic disease realm and in the HIV world, certainly makes a lot of sense. There's so much that can be done upstream, so much that can be done from a community or a state perspective of trying to improve the possibilities for health for folks.
Thomas Dobbs:Then so during my residency, I did a master's in public health at the UMB School of Public Health. I kind of, I did it during my residency. I had some time off to help, take care of our youngest child, but then also too, I did it during residency. I didn't, tell the residency program and actually had to sneak away to take my tablets. I still don't know that they know that I was doing that, but anyways, fantastic experience, and then, after training, ended up working in South Mississippi and did, worked in South Central Regional Medical Center in Laurel, Mississippi, and also started working, with the community health center in Hattiesburg, treating folks living with HIV.
Rob Lott:What did you learn from those early experiences?
Thomas Dobbs:Before that, I'd also been doing tuberculosis work for a long time and got a really neat exposure to public health. From that perspective working with mentors at UAB, specifically Doctor. Michael Kemerling. But then once I came to Mississippi, it was really kind of a remarkable experience because I learned immediately that it's not the science of medicine that's the challenge. Although it's beautiful what we've invested in the science of treating and preventing HIV, it's really kind of remarkable what we've been able to do with intention and investment.
Thomas Dobbs:But it wasn't the technology, it was the challenges that people had in their daily life, right? It was like, you know, I thought I was going to go into healthcare as a clinician scientist, right? It was the intellectual part that I was going to bring to the community that I'm working with. But really, learned pretty quickly that it was substance abuse, transportation barriers, lack of insurance, all those things that make it really hard to be healthy, that I spent the majority of my time working on. And that really helped me get a different viewpoint of what is really driving health in our country.
Rob Lott:Okay, so over the years, in addition to practicing direct patient care, you've gotten more involved in population health efforts, eventually becoming a public health officer, a state health officer. Can you tell us a little bit about that journey and kind of how you went from the bedside to the kind of the boardroom, if you will?
Thomas Dobbs:Yeah, so there is no clear pathway into sort of public health leadership. Early on when I was trying to meet with people to understand how do you get involved in public health? There's a bunch of different pathways and I think everybody has a different way of getting there. So I was a clinician, I think working in tuberculosis and HIV, there's a natural overlap with public health because a lot of the work that you do is, you know, working in communities, trying to prevent transmission, identify people exposed, and that sort of thing. I started doing the tuberculosis consulting for the region in 02/2005.
Thomas Dobbs:And I'm actually still doing it to this day. So it's still doing that. And then from there, I took over the local leadership role, the regional health officer role, and practiced a little bit. So I've kept my HIV practice going pretty much nonstop since early on, at least in some way or another, and really sort of learned how the public health system can work effectively and sometimes ineffectively at trying to improve health for the local communities.
Rob Lott:I want to circle back to the tuberculosis consulting work. What does that job entail and sort of how has it changed over the last few years?
Thomas Dobbs:You know, remarkably, job hasn't changed much in the past thirty years. I started doing it with friends and mentors in Alabama back in the 90s. And a lot of it is supporting the nurses and the public health professionals to review cases and make sure that things are managed properly and to help do outbreak investigations and prevent transmission. A lot of it's the same, technology is different such that instead of having a light board on my wall to look at the x rays, I look at them on the computer. But, but, and then, you know, electronic communications certainly make things a lot more, more efficient, but the work is, is essentially the same.
Thomas Dobbs:The thing that we do have going on and that's its whole interesting sort of conversation with tuberculosis. I think it's a good sort of mirror on what's happening in public health, you know, but we've lost so much experience and so much institutional knowledge in tuberculosis, but in so many other fields. I do a consultation role with the University of Florida for the Southeastern Part Of The United States for regional consulting for all the states if they have sort of complicated questions. And I'm seeing that public health has really been decimated when it comes to the number of employees. And we've got a lot of young faces who are talented, but the challenges are just really overwhelming.
Thomas Dobbs:And I'm really worried about the public health future of our country.
Rob Lott:What do you attribute that change to that loss? I mean, I know we certainly have had cuts to investments recently, but I presume that this was happening before January of twenty twenty five.
Thomas Dobbs:Yes, it has been. And I think what's going on now is just a continuation of a long standing narrative of our underinvestment in public health infrastructure. It's something that I've really been on the soapbox about for a long time and it's never gone anywhere, right? We've basically traded public health for advanced biomedical technology and so if someone's really sick and when they need CAR T therapy and all that kind of stuff, amazing, I love it, but we are way under invested in the blocking and tackling that it takes to protect the public at the foundational level. And I think that's one of the reasons why if you look at our life expectancy and our excess avoidable deaths, we are an outlier for the world.
Thomas Dobbs:You know, I mean, we exist in a plane that's almost unimaginable and if you really just step back and look at it and people don't know it, I mean, people are sort of like the frog boiled in the water, I mean, we've just gotten so used to it, you know, that, you know, gun violence deaths, early deaths related to heart disease, stroke, know, general status of health is so poor compared to, you know, other developed countries, even with a lot lower income. It's, yeah, I think it really reflects our lack of investment in a public minded community approach to health and well-being.
Rob Lott:So let's say you had control over how we were allocating funds and, or perhaps you just have the ear of folks in Congress who are doing the appropriations, besides simply saying, spend more on public health, what are some of the areas you think really could benefit from targeted investment and that that investment would pay significant dividends?
Thomas Dobbs:You know, this is going to sound kind of strange, but the first thing I would do is not ask for more money, I would ask for more flexibility and stability, right? Because what we end up doing is we have these sort of like boluses of money that come in targeted for something like Ebola, or Zika, or whatever. And so it's really kind of like a roller coaster. And we build some specialized capability that doesn't translate into long term and then the money gets pulled away, right? We could spend a lot less money and build a lot more robust infrastructure if we just provide some stability.
Thomas Dobbs:The other thing that we've seen, and I think it's particularly bad in the South, is for a whole host of reasons, we don't invest in our people and we pay pathetically low wages for our experts in public health, our nurses, our disease investigation specialists, all these folks, and the world outside of the government, the pay has increased pretty substantially, but for public health and the government health, and I think part of that is intentional by folks trying to cut costs or shrink government, it basically leaves us with an inability to recruit some of the best talent that could really have major impacts on the well-being of our state and also in the populations that need us most.
Rob Lott:You mentioned the particular challenges in the South, and I know Mississippi has long placed on the sort of lowest tier of states when it comes to many population health measures, things like premature death, low birth rate, cardiovascular disease. How significant was that fact within your own mindset when you took on the role, Love leading the state health department?
Thomas Dobbs:You know, it's huge and I think there's a lot of interest in sort of like getting into that and trying to figure out how we can make progress. It's a real challenge because people don't really want to address the core causes, right? A lot of what we do is at the surface, right? And some of it's really good. I mean, can certainly treat high blood pressure and stuff like that, or, you know, try to open a clinic here and there.
Thomas Dobbs:But if people don't grow up with a healthy environment and a pathway to health, then the long term trajectory is not going to be great. And so I think thinking upstream is something that really we've been trying to do. What I had sort of initially hoped to do with the health department changed pretty rapidly once COVID hit. And so then it was all hands on deck. Now, one of the things that happened with COVID that I was just shaking my head because I knew it wasn't going to work out well in the public health sort of, you know, space, there was all this talk about, oh, we realize how important public health is and oh, we're going to invest.
Thomas Dobbs:Oh, we see how important you are. And I was just thinking to myself, I have seen this before. I've seen this movie before. And once the acute scare is over, the money gets pulled away and we backslide and continue our disinvestment in one of our most valuable institutional resources as a country.
Rob Lott:Well, in a minute, I want to hear a little more about your experience navigating the COVID pandemic. But first, let's take a quick break. And we're back. I'm here with doctor Thomas Dobbs, dean of the School of Population Health at the University of Mississippi Medical Center and the former state health officer for the state of Mississippi. Just a moment ago, you were talking a little bit about the sort of disappointment that came following the high hopes for perhaps some transformation to our public health system post COVID and then the inevitable sort of backslide there.
Rob Lott:In fact, you were the author of a paper that we published in Health Affairs, where you studied non urgent elective procedures, intensive care in Mississippi. And I'm wondering if you can just say a little bit about that and kind of how your work on that paper fit into your broader experience leading the COVID fight in Mississippi.
Thomas Dobbs:So I would like to say that I think we may be missing a great opportunity to learn from the last pandemic to prepare for the next, because we did so many things, right? We did so many interventions, we did the mask thing, we did the social distancing thing, we did a lot of controls over hospital admissions. There were a whole sequence of things we did to society and we don't know what worked and what didn't work. Mean, to some extent we do know somewhat different things, but we really haven't done the type of investigations I think that we could sort of hang our hat on where with the next pandemic we can have a list of options. Say, okay, this works in this scenario, this works.
Thomas Dobbs:And so that's what we wanted to do. One of the things that we did in Mississippi and one of the things I think that really challenged a lot of places, that I do think it was worse here because our baseline resources are so low, is that when COVID got bad, our health systems were overwhelmed. And the inter hospital transfers were blocked. It was basically concrete. And we had people who were like having heart attacks in parking lots and couldn't get to care because the ambulances were backed up, their hospitals were full and they wouldn't take anybody.
Thomas Dobbs:And so we did a couple of things to try to like loosen up the system a little bit. One of the things is if you need a knee replacement, it can wait a week, it can wait a couple of weeks, right? But those are resources that eat up hospital capacity. And it's not just like, oh, and I had the doctors complaining and saying, oh, it's a knee replacement, it's an outpatient thing, it's not going to use up any resources. But when we looked at the data, we saw that like ten percent of knee replacements end up hospitalized unintentionally and about five percent in ICU, at least temporarily.
Thomas Dobbs:And like, okay, those are resources that we're trying to preserve. So that was the premise we went into it with is that we should delay these non urgent elective procedures to make space for critical resources that we need in the hospital. But after it's over, we said, okay, we did this, right? Did it work? And so that's what we did is we did a study to see is, was this policy effective in making more ICU beds available?
Thomas Dobbs:And the answer was yes. And we didn't get into the question, did it make more general, you know, medical surgical beds available? But I think it probably would bear out the same way. And I was glad that we had an opportunity to sort of try to answer one of these questions of was something that we did, was it worthwhile? And I think that this demonstrates pretty clearly that yes, it was a worthwhile logical intervention that we can put on our list of things that we can do in the future when we get in these sort of challenges.
Rob Lott:So I'm so curious in that context, so many of the papers that we publish at health fairs are written by academic researchers. That's their sort of almost their full time gig is to connect these studies, write the papers, submit the papers, publish the papers. And often when we talk to folks who are sort of either practicing physicians or public health professionals, what we hear is, Oh, I have this great thing. If only I had the time to write it up, you know, or the resources or the support. And I'm curious sort of if that kind of equation was something that you grappled with?
Rob Lott:Did you set aside the time to work on this? Or was it the kind of thing you had to do nights and weekends just to make it a priority?
Thomas Dobbs:Yeah, gosh, it's such a good point because there are so many smart people out there who are too busy and under resourced to do things. You know, fortunately, working for the health department at the time when we pulled this together, And then shortly thereafter, my role was such that I was able to put some time into it. And there was some, you know, some after hours weekend sort of time on it. But I'm not like a busy clinician, you know, trying to make money off RVUs, right? And so I think in a way that kind of speaks to the value of having people whose job it is to figure this out.
Thomas Dobbs:I mean, that, you know, that's to be some of the stuff like CDC is doing. And I think, you know, CDC missed a bit of an opportunity. I know they have their own challenges and have ever since COVID and thereafter to look at some of these questions, because even like even to this day, you know, things that were sort of like a little bit controversial, people ask me like about the masks. You know, I'll give a talk and people say, what's this nonsense about the masks? Or did they work?
Thomas Dobbs:And so I have to give them what I think is an evidence based reasonable answer based on the collective information that I have. But I don't think we have a definitive science around, you know, what is a proper public mask policy in the setting of a pandemic. I think that we have not done a good job of assembling the necessary data to be unequivocal in this works, this doesn't work, this makes sense in these circumstances. I think unfortunately, you know, we're not going to have that information when the next need arises.
Rob Lott:What would that look like to to be able to give an unequivocal response? I know this is unlikely or or kind of idealistic, but what would we need to have in place in order to be able to answer those kinds of questions in a timely fashion?
Thomas Dobbs:You know, you could probably do, you know, almost like a quasi experimental thing, looking at different communities around transmission, whether or had like, know, mask policies here and there, I think, you know, school settings and those sorts of things certainly help to of do it and there are some smaller things, but you know, think some other countries who had sort of like a bigger sort of perspective about looking at their whole population, England, Israel, you know, they put out some really good stuff that sort of answered some questions. And, know, I don't think that we had that sort of foresight. We were always sort of like, you know, running behind the truck, right? We're always trying to catch up instead of thinking ahead say, Oh, you know, we have this really important question, we can sort of do some stuff ahead of time. But I think, you know, not to be too critical, because we were just trying to get through everything.
Thomas Dobbs:But, you know, the data could have been out there. But, you know, we wasted a lot of time with other stuff that was probably a little bit unimportant. Duplicated data reporting and all kinds of stuff, outmoded reporting systems, you know, that's one of the things too, that I think that I'm sad that with our, you know, reportable disease reporting, had to build an infrastructure that because it was bought with emergency funding has been actually dismantled because now it s going through a procurement process, the whole sort anyway.
Rob Lott:Yeah. It's a little bit of a Jenga tower or something like that where you're trying to adjust in the middle of building at the same time. And I can imagine that without a sort of someone taking a step back, it's hard to know exactly where to push and where to pull. That's a great analogy. I do want to shift gears just for a moment and just acknowledge your name is attached to one of the most divisive Supreme Court cases of recent years.
Rob Lott:And I'm curious if you can tell us a little bit about how that happened and sort of what that experience has been like for you.
Thomas Dobbs:It's not universal knowledge, And it's not even common knowledge that there's a sovereign immunity clause, in the constitution where you can't sue the government, at least I think that's the best way to explain it, and I'm not a lawyer. And so what happens is that if you sue an entity, a regulatory entity, a person's name has to be put on it, Right? And so what happened was the clinic here in Jackson, sued the government, but the regulatory authority was the health department who was the inspector, as under sort of like the the inspection panel that they would do for an ambulatory surgery center.
Rob Lott:And this was a dedicated reproductive health care clinic in Jackson, is that right?
Thomas Dobbs:It was, yeah, yeah, yeah. And so, so the initial lawsuit was Jackson, women's health, or I can't remember exactly the name versus Courier, Doctor. Courier, because she was the health officer at the time. And she had nothing to do with it. Right?
Thomas Dobbs:And so when I took the job after she left, the naming convention automatically replaced her name with my name. I had nothing to do with that case at all. I didn't testify, I didn't try to do anything, I didn't want to have any part of it. And it just, you know, it's just one of those things. If you're a public official, you have these sort of vulnerabilities as far as like, you know, the stuff that's gonna happen, and so it went through, and you know in December, which was right during the explosion of the Omicron, the Supreme Court chose the Mississippi case, which I didn't have any foresight into that.
Thomas Dobbs:And so from there on it happened and I tried to see if there was a way to pull my name off of it and they said nope, too late. And that was it. That's how it happened.
Rob Lott:How has that affected your your day to day work if if it has at all?
Thomas Dobbs:It mostly hasn't been too impactful for the most part because, most people day to day don't even realize it, right, because they don't really, you know, know about that and certainly because I haven't been, you know, active in that world at all. I did get some good advice early on and basically someone told me to, you know, lay low, just stay out of the fray, and if people ask me I just explain it. I get hate mail and love mail and I respond the same way, thank you for your communication, and I send them an article from the New York Times that says, hey, this guy had nothing to do with it. It's just kind of one of those quirky things. Just try not to think about it as well.
Thomas Dobbs:I mean, it's kind of I don't know, just kind of a strange thing.
Rob Lott:Well, in July of twenty twenty two, you stepped back from your role as a state health officer and have since become the Dean of the School of Population Health at the University of Mississippi Medical Center. What have you been able to focus on in this role that perhaps you couldn't, in your previous roles?
Thomas Dobbs:I have been hopeful and am still hopeful to engage the clinical academic community to fill some of the gaps that exist within the public health world. Part of that is, you know, there aren't that many public health clinicians anymore. And so I'm still very active in TB control and in STD prevention, HIV treatment and prevention. And so we've had some pretty good headway in those areas, But it's also given us an opportunity to do some sort of research, some landscape analysis, educational work, and we have some cool things going on that think are going to be important for our future. Based on my life experience, at least as long as I'm alive, we're never going to give public health a reasonable investment.
Thomas Dobbs:But where do we spend trillions of dollars, trillions of dollars to low impact every year? In the health care, right? I mean, you spend so much money and so part of my dream is to figure out how do you incorporate public health practice, at least the elements that can be done as part of the healthcare system, into the clinical environment. And part of that's going to be training the next generation of clinician leaders. You know, we have some interesting things going on with CMS right now around social determinants of health, I think they're important and that I hope will stay.
Thomas Dobbs:We're looking at some innovative approaches toward our maternal health crisis and infant health crisis here around group based prenatal care and integrating it with helping women with their health related social needs. So I think a tighter marriage between the clinical resources and also with community health centers. I think that's our future. We still need public health desperately and there's some things that public health only can do like contact investigation or intervening, you know, testing contacts to STDs. I mean, private doctor can't go to your boyfriend's house and test him for so forth, right?
Thomas Dobbs:That'd be interesting. So anyway, I think there's some neat roles we need to think about. We need to be innovative because my hopes of the past have been repeatedly dashed and I'm going to change my perspective.
Rob Lott:Well, that's a great segue. As you're saying here, the outlook for public health departments at the state and local level has gotten sort of cloudier in recent months after having long been stretched thin for for many years. What advice do you give to your students who might come to you and express sort of doubt about the future of the field and whether or not they should even pursue public health and population health as a career?
Thomas Dobbs:You know, now is kind of a challenging time and so it depends on who's asking me. So if you have something else you do, right? So if you're a physician, if you're a nurse, if you're a healthcare executive, if you do something else, I strongly encourage and recruit them to get a public health degree because it really elevates their capabilities, not only to advocate and improve health from a community level, but also to be better sort of scientists, right? I mean, we saw some of the most egregious things happen during COVID, even among sort of clinicians who were kind of didn't really understand science, right? And so would make these wild, assumptions, right?
Thomas Dobbs:So it's important to understand the framework. I mean, the kind of analogy I get is like everybody thinks they're a public health expert, right? But you know, I don't know how to fix the transmission just because I saw a scary YouTube video about transmissions, I'm not going to go try to fix my transmission, right? And I think people, I don't know, it's important to understand that there is a very precise science around all this stuff, I want to train better public health scientists. Now someone who just wants to get an Miles hour to go work at the health department, I think it's a tough time.
Thomas Dobbs:I just don't think those jobs are going be there, I'm just being honest. You know, eventually, you know, we'll have to rethink how we're doing this, but you know, right now we're seeing layoffs, not hiring.
Rob Lott:Wow, well, so a realistic take on the current state of the world. Any other final thoughts for listeners about your experience and what you might want to share with them?
Thomas Dobbs:You know, the only thing I just want to just reiterate is how important public health is. If we think about our gains in prosperity, expectancy over our entire nation's history, it was rooted in disease prevention and having healthy communities, healthy water, healthy food systems, those sorts of things. And we do not need to abandon those foundations, right? It's why do they have cholera and typhoid in certain undeveloped countries? It's because they have abandoned those systems or they never had them, right?
Thomas Dobbs:And I worry about our mad rush to health individualism, right? Where everybody's responsible for their own health. Everybody can't be responsible for a sewer working, right? Everybody can't be personally responsible for making sure they're not lead in their water. There are some community responsibilities that are critically important.
Thomas Dobbs:It's okay to have a public conversation about what those are, but we cannot abandon them. We not only need to recognize them, we need to fortify them. America's health is bad. We perform very poorly. Women's health in Mississippi and infant mortality ranks somewhere between Algeria and Turkey, right?
Thomas Dobbs:So that's not something to be proud of. We need to invest in the foundation that allows people to be healthy, allow people to make the individual decisions that they can to achieve maximum prosperity and health.
Rob Lott:Well, that's a great place to wrap up. Think Doctor. Thomas Stubbs, thank you so much for those thoughts and for taking the time to chat with us today.
Thomas Dobbs:Thanks so much for having me. It's great to talk to you guys.
Rob Lott:And to our listeners, thanks for tuning in. If you enjoyed this episode, share it with a friend, leave a review and subscribe. Thanks so much. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a healthy podcast.