After nearly 15 years at the Mississippi State Department of Health, State Health Officer Thomas Dobbs is stepping down at the end of July, marking an end to a long career in public health capped off with the pandemic of the century.
In late April, Dobbs joined Mississippi Free Press reporter Nick Judin for one last interview as head of Mississippi’s public-health agency, to discuss the future of the pandemic and the institution, and to reflect on the lessons of more than two years of pandemic crisis management.
Nick Judin: First of all, congratulations on your upcoming transition.
Thomas Dobbs: (I’ve got) many conflicting emotions. In many ways I’m very sad to go, but also looking forward to new opportunities and, you know, getting new leaders in place here.
Your departure is coming at an important moment in the COVID era. The pandemic isn’t over, but we’re clearly in a new phase of our response. How are MSDH’s mission, role or priorities changing with the new leadership?
Well, just from the perspective of the pandemic our role is changing. It’s a very different situation. Now we have a lot better scientific understanding (of COVID-19). We have a lot more tools. We also have a population where more than 90% of people have some underlying immunity, right?
So we are shifting back into our gap-filling and support role. We’re making sure that doctors know what they need, making sure people have access to treatment, doing public education, and hopefully we won’t have to do any direct interventions like we have during the pandemic.
I think we’re transitioning away from a public health-oriented response to a medical response. The surveillance aspect and all of that are always going to be (our) public-health responsibility, but we’ve got to have doctors and health systems ready to do the diagnostics to make sure that people have access to treatment. That’s going to be a big piece of it.
Now, as far as future leadership goes, we think we’re going to keep going without skipping a beat.
In many ways, we appear to be in the worst position so far with regards to the medical landscape. COVID-19 has wrenched apart a system that was already damaged. It has depleted our healthcare workforce. It’s frayed our supply chains. What does repairing the system entail, and who are all the players who have a role in making that happen?
Boy, that’s a huge one, and a lot of folks have a role.
If we’re talking about the health system, what’s most vulnerable right now are our hospitals, where they’ve lost so many nurses. We asked a lot of our inpatient folks, of our emergency rooms and our intensive-care units. It was just exhausting.
The outpatient health system doesn’t seem as stressed. I’m not saying that they don’t have vacancies, but the functionality of it’s still pretty there.
It’s the inpatient health system. And it’s variable. Some places are doing OK. It’s going to take leadership and salary support. But a lot of the (challenge) will be more the long-term (issues). We’ve been short of nurses for a long time. We have gaps along the educational train, right? And this isn’t something I’m just saying.
The nursing leadership says they don’t have enough faculty to train new nurses, right? We don’t have the infrastructure and capacity. We need to have a long-term plan to bring on a lot more health-care professionals, especially nursing folks. It’s a fantastic career with a good bit of flexibility.
That’s one piece of it. The other is that a lot of states didn’t have as much trouble as we did because they had a more resilient health system to begin with. Because they were better funded (to begin with.) They had more doctors per capita, more nurses per capita.
So we started, per capita, lower. You’re just starting with a bit of a challenge. You add our health-system problems within the Jackson area—in the sense that it’s really a regional referral center. It tends to get clogged up just because there’s so much stuff coming here.
So there’s a need for more specialty referrals and ICU capacity, so that when (other medical settings) send folks in, Jackson is a little bit better off.
In the north part of the state, they tend to go toward Memphis. In the south part of the state they tend to go toward Mobile or to Louisiana. They still had significant problems, but it was just different for folks who use the Jackson market, which is super, super busy.
You’ve touched on quite a few pieces there: workforce development; expanded nurse education, training and retention; a stronger central healthcare market. But who has the primary responsibility to get those balls rolling? The Legislature? The governor? Hospital leadership? Who can serve as the prime mover here?
A lot of people have a role, certainly. The governor and Legislature have huge roles. The governor has a lot focused on workforce development, and a big part of that has to be health-care workforce, especially.
Same with the Legislature. There’s things that they can do to support that. They can make sure they’re supporting nursing schools … to make sure that there’s funding both at the community-college level and at the university level.
Beyond that, the nursing schools themselves need to do more. And I think they want to do more. I’m not sure what the solutions are. (For example), bringing in more faculty. I think that’s a big bottleneck.
There’s also innovative things we can do to make sure we can try to get nurses to stay, right?
Like scholarships. I know that was discussed (at the Legislature.) I don’t think anything came out of it during this legislative session. (We need) something that gets nurses to stay. If we train a nurse in Jackson we want them to stay in Jackson. We don’t want them to just go to New Orleans or Memphis. Some of that is money, but a lot of it is that young folks just don’t want to stay in Mississippi. We have brain drain. That’s a real challenge.
It’s a combination of a lot of stuff. Everybody has a place in this. Hospitals have a role to pla,y too, because they’re locations where a lot of the nurses are trained in their clinicals.
And so. The hospitals need to be very active there. … And that’s also a great way to recruit nurses, because they get to experience your hospital, they get to meet people. There’s a lot of players involved in all of this.
It’s going to take some convening of the leaders who are over these different groups to bring it all together.
You pointed out the role that the governor has, the role that the Legislature has. Are they playing that role? As you’ve pointed out in the past, this is a state that has cut funding to its state health agency right in the middle of a pandemic. Where are we now? We’ve now had three pandemic legislative sessions. What change have you seen? Where’s the urge to address these problems?
More has to be done. Without a doubt. The physician side is getting some help, but the nurse side needs more. Without question.
I know that there was an effort to revive the nurse scholarship program that the board of nursing has. So much has kind of flown through. I don’t know if that came through, but that was something I know they planned to do, and that’s a good start.
(We should) fund the nurse retention scholarship plan like we have for doctors. There’s one on the books for nurses. It just hasn’t been funded. Hopefully now it has been.
(Editor’s note: Multiple nurse retention packages died in committee this session.)
That’s super important. Also, I’m not really sure about the funding package for our community colleges and our Institutions of Higher Learning folks and, you know, but hopefully they’re getting the support they need to fulfill that mission.
And when it comes to brain drain?
It’s tough. I see a lot of folks who are my kids’ age and a bit older who—they want to go to Nashville. They want to go to Birmingham. They want to go to other places around here that have more dynamic opportunities for young folks.
In Mississippi, and this is just my opinion, but Jackson could serve that role. That would be a natural draw. We have big medical centers. We could also have the cultural foundation for fun stuff to do.
In Nashville they have country music, and they’ve got a lot of great businesses. I was actually speaking to somebody who lived in Nashville when the city made that transition from a sleepy country town into a business center with a lot of vibrancy and, you know, I don’t see any reason why it couldn’t happen for Jackson.
But you have to have an urban area that attracts youth. And I don’t think we have it.
You’ve had a long career at MSDH. You have a background in infectious disease. Through this pandemic, what has shocked you the most? What were we the least prepared for?
Well, I’ll tell you, what shocked me the most is how little people were willing to do for their neighbor. Just to be honest. Not that it was universally that bad, but a lot of the resistance we had to stuff was “It doesn’t affect me. I don’t care. You can’t make me.”
And MSDH didn’t really do any mandates because that’s not our role, except for entities over which we have licensing authority. But just recommending folks wear a mask, those sorts of things, because you want to take care of your neighbor and your sick grandma.
It surprises me that that didn’t resonate more in a place like Mississippi that prides itself on being hospitable. I know that’s a small surprise, but you know, these are people who otherwise would probably go outside with a chainsaw and help you cut a log out of your yard if you were having trouble. I don’t know. But that connection just didn’t happen. Maybe it’s something we could’ve done better, but this was a national thing, not just Mississippi.
As far as preparedness, the (personal protective equipment) shortage upfront was the most alarming. It’s not something that any state has specific control over. We had a reasonably decent supply of PPE going into it, but when the supply chains got totally shut off, and we were having a lot of hospitalizations, that was extremely stressful. That was something that as a public-health professional, I didn’t really have on my radar.
I mean, we had a million masks in our stockpile. And we thought that was pretty good. But now, obviously, as we look back, it was wholly inadequate. It was meant to supplement the supply chain, not to replace the supply chain entirely.
The other thing that was pretty tough for us—it was really kind of bonkers the federal government basically sucked up all the supply and shifted it to areas of highest need. Because there was need everywhere. And so we ended up having to basically compete with an unlimited federal checkbook to try to bring in more PPE. That was a crazy thing to witness, honestly.
Beyond that is the health-equity bit: We were surprised early on when it was mostly Black folks getting COVID-19. And we’re glad that we had a good health-equity team that we could turn to for work with our minority communities.
Whenever I spoke to nurses, doctors, anyone who worked in a care setting in this pandemic, I heard the phrase “just-in time management” come up. Our system runs on thin margins and finely tuned plans. Have you been party to any higher-scale conversations about how to change that?
That all happens on a federal level. I’ve certainly mentioned it in certain conversations with folks, but it’s outside our control.
It’s the same thing with microchips, right? You can’t have a razor-thin supply chain that has to come across the Pacific. Because then you’re left at the mercy of external forces. And even if you have a backup supply, an inventory for emergencies, that can only go so far.
It took a long time to ramp up new production within the United States. We did some innovative things in Mississippi. Some of our factories retooled themselves to provide masks and other supplies within the state of Mississippi. But that’s not medical quality. That was really more for the public. There’s a whole FDA review process to be able to get medical-grade PPE.
So I would say that we’re continuing to be under-prepared in our PPE supply chain. I don’t see anything that gives me any sense of relief that if this happened again—other than having slightly better inventory of emergency supplies, that we’d be able to weather it much better.
It seems like we haven’t been able to address the supply-chain issues. We haven’t been able to address the medical-system funding issues—nationally and as a state. We haven’t even really come to a conclusion on, as you brought up, the ethos of protecting our neighbors. We are about to hit a million confirmed, recorded deaths from COVID-19 in this country. If we haven’t learned these lessons by now, where’s the light at the end of the tunnel?
Sadly, I don’t think we’ve learned the lessons that we should have learned. We have learned some good lessons, but … one of the things that’s strange has been (caused by the fact that) the mortality rate was relatively low per case, right? In Mississippi, about 2% of diagnosed cases (were fatal). There were other cases that were never diagnosed, so that’s not the real mortality rate.
If everybody gets it, that’s still a lot of people dying, but it’s a low enough rate that if people want to deny the seriousness of it, they can say “hey, I know 10 people who got COVID, they’re fine. They didn’t die. Only one of them went to the hospital.”
But then out of a million people, even a 1% mortality rate, that’s going to be 10,000 dead folks. It’s just not OK. I don’t know why we’re OK with—13 dead children, 15 dead pregnant women—saying that’s an acceptable loss. That’s not, to me, a remotely acceptable loss: to lose over 12,000 Mississippians.
A large majority of whom could have survived! If our mortality rate were the same as Vermont’s, we would have lost about 2,800 people instead of 12,500. There is a lot that is lamentable about kind of where we are.
You said we’ve learned some good lessons. What are some examples of those?
There are lessons we’ve learned—I’m in public health. I don’t know that the whole general public, who don’t pay attention to this on a daily basis, gleaned as much from it as would be desirable. A lot of people did. I think some folks do see the value of (public health) a little more.
From (the public health) perspective, having uniformity and aligned communications nationally and throughout the chain makes a big difference. It’s really difficult because of the way that our public-health system works. Most authority lies in the states. So when you have 50 different state responses, it seems like it’s disjointed because it is disjointed.
The other thing is (the importance of) using the right message at the right time. You know, we’re at a different phase right now in the pandemic. Certain interventions make a lot of sense. But you can’t burn your powder on every (fight.) You can’t die on every hill.
I think that, (for example), the vaccine mandates potentially made a lot of sense back in the summertime before delta, but rolling it out after omicron didn’t make a lot of sense. What it did do was make a lot of people mad.
It does make sense for certain subgroups. (Centers for Medicare & Medicaid Services) did it, we do it for health care all the time: for measles and tuberculosis. We have certain things that health-care employers and employees have to do.
Finally, be thinking towards the next problem. Through the pandemic, a lot of our work was directed at solutions to problems from three to six months ago, instead of a solution to the problem that’s going to be ahead of us in three to six months. Thinking ahead is very important.
Part of that is because the process to come to an intervention is slow and deliberate, but we need to have these solutions preloaded. As an example, surveillance of wastewater is kind of a big thing. Now people want to check it for COVID, right?
Well, I would posit that, sure, that’s fine. But we don’t need to be using it for COVID so much, because we have good diagnostics. We’re going to see COVID pretty quickly when cases come up. (Rather) let’s be thinking about if there’s an introduction of polio. Or if there’s some new virus that’s out there where we don’t have millions of rapid diagnostic tests sitting on people’s shelves.
We want to be able to say, “Hey, we’ve had importation of polio from say Afghanistan. We need to be able to do stool surveillance of wastewater.” Thinking ahead in that sort of way is going to be important. And hopefully we can learn that lesson: to be thinking forward thinking and not backwards thinking.
You have experienced personal attacks. You’ve experienced actual threats. I have personally witnessed you painted as an agent of the New World Order, a pawn of big pharma and a communist doomsayer.
(Dr. Dobbs laughs.)
I know you don’t think of your job as political, but in a sense, the pandemic—and the response of some groups and individuals—has forced a political character onto this role. How has that changed your job, and how might that change the work for the people who come after you?
I think it’s just part of the normal resiliency that you have to have. You have to just be willing to take it and roll with it.
I know that sounds fatalistic, but you can only do so much. The other thing is that sometimes we’re talking about squeaky wheels, right? It’s the crazy voices that get the attention. In spite of the polarization of the response, overall I’ve been very well supported by political leaders, the governor, the speaker of the house, the lieutenant governor—the (Mississippi) House even gave me a commendation.
I think that was universally voted positive on. So I don’t think that the general voice speaks as loudly as the crazy voices. That’s a real problem, and I think that’s good to learn. And getting support makes all the difference. Because I’ve got a whole stack of people just saying, sorry for all the junk you have to deal with. Thank you so much. Those little things make a lot of difference.
If you just hear the crazy voices on Facebook, you would think that something is really rotten out there. And also I think it’s really good that Facebook was willing to ferret out some of these things that were the most egregious, things that were not helpful, but harmful and even threatening in the public discourse.
I want to turn this around a little bit—how has the media failed us, or at least struggled during this pandemic?
Well, I think it depends on how you parse out what is media, right? If you look at social media, especially unrestricted social media, there the conspiracy theorists gained great traction and there whatever’s salacious goes fast, right? If you say something outrageous, people want to look at it.
But even though it’s outrageous and (maybe) people don’t really believe it, it plants a seed, and that’s dangerous. I think it’s incumbent upon people to be careful what they put in their minds. I’m not going to go and eat a dozen donuts for lunch, but people don’t mind filling their brains with an hour’s worth of nonsense on Facebook.
And it’s equally damaging, I think. Then if we look at cable news I think that’s a real problem. That’s a type of news that really is not there to give you information. It’s there to soak you up and manipulate your emotions. I think that’s a real challenge. I personally don’t watch any cable news. I mean, I guess I watch NPR, right? That’s pretty dry.
I think a lot of the media, like you guys, especially local news, have been pretty straightforward and extremely helpful about just reporting things directly, not trying to get spin.
There is a mainstream to consumer information sharing—done through a lot of the media modalities—and it’s extremely important. And it’s important to separate that out from the shrieking heads on cable news that get people stirred up.
You said you’ve been supported by political leadership in the state. There have also been ways that political leadership nationally and in Mississippi have positioned themselves against intervention. What’s your critique of the way that political leadership and public health leadership have clashed, whether in Mississippi or across the nation?
You know, some of my wiser and more seasoned colleagues in my same job in other places have had a pretty good observation. As an unelected agency leader, a lot of the role for us is to be an expert in our field, provide guidance and try to make sure that the politically elected folks can make the best decisions.
In Mississippi, all the general mandates and everything came from the governor’s office. And certainly he took some very brave stands, especially early on. I know he’s probably been criticized a lot for it, but it did save lives, and it did work, even though it was painful and had negative consequences.
But they’re reflected by the electorate, right? If the electorate has a greater interest in individual freedoms compared to collective safety, I mean … that’s a debate that happens on the grand political stage. And of course it’s obviously influenced by party politics on each side, about who they choose to cater to.
From that perspective, it would appear that it’s the baseline politics that drives (those decisions). If people wanted greater security and public safety and collective efforts toward health, then that should be reflected in the electorate.
We can work on our own to do things individually with groups and through partnerships. And we have successes in that. But I think that a lot of our challenges were in that deferral to absolute individual liberties, where some simple interventions that were minimally impactful, that certainly wouldn’t impede people from making a living or going to school could have been more effective.
You’re saying political leadership is responding to that urge more than driving it themselves?
How do we address that urge against any collective action? Is that on the media? Is that on leadership? How is that done?
In Mississippi, where we do a lot of deferring not just to individuals, but also to local governments, there is a zone of opportunity in working with cities and with local communities. We’ve had a lot of great relationships working with Oxford, Starkville and Hattiesburg. Jackson was very proactive, and I think a lot of people made brave stands and saved a lot of lives.
And there were some other cities that were the exact opposite. Some were very difficult, and I won’t call them out, but … (local engagement) is an opportunity. Plus working with specific communities that are outside the political or the geographic boundaries. Faith communities, right? That’s its own sort of population. Business leaders, that sort of thing.
It’s about finding those zones of opportunity where we can work and influence people who have authority over different folks beyond statewide political figures. That’s really where our opportunities arrive.
Before you go, I want to talk about health equity. Mississippi has, for various reasons, underperformed during the pandemic. We’ve had the highest death rate of any state. But there’s also evidence that some of our health-equity work has outperformed other states. Can you describe some of these efforts? How can MSDH expand those efforts, and will it do so?
Once we realized that COVID-19 had such a harsh impact on Black communities, specifically in the African American community in the number of cases and deaths, we did a hard pivot and made sure that health equity was on par with all the other things we were working on.
We elevated Dr. (Victor) Sutton and his operation to the senior leadership, so that whenever we talked about anything he was part of the conversation. That worked great, not only to drive the objectives, but also to make sure what we’re doing took into consideration these folks.
Although we’ve gotten some federal money directly toward health equity, a lot of our FEMA response funding, other grant funding, even immunization funding has also funneled to that same effort. It’s not that we just got one little pot of money for health equity, which we did and we’ve used it, but really we integrated it into the whole operation. That was very important.
One of the things we did early on, and—really this was just letting Dr. Sutton and his team do what they need to do—is we listened to folks. We listened to the mayors of Black communities and faith leaders and other folks.
And that was really easy. That was useful to help identify and dispel myths, to see where the gaps are, both in the access to resources and also access to good information.
That helped us tailor our programs such that we could meet folks where they were. We had a whole network of internal and external partners who were paid through our programs to do church drive-through vaccinations. All you had to do is call a number, and we could set up any vaccination site within a few days or a week.
Setting up those networks was really good. Same thing with PPE. We’ve given out probably a million masks just through our health-equity effort. I know we’ve given out about 300,000 tests in addition to the federal ones. I think it was very useful.
We also made good inroads into our Spanish-speaking communities, who have been historically disenfranchised and can have a certain wariness of government officials. Our Hispanic vaccination rate is on par with our white folks—which is too low, and we want to do better, but I think it speaks to how we have made some progress, where initially it was very low.
The challenge is going to be expanding it to other areas. I think what we do have as an advantage is these networks that we’ve built out and these relationships that I think will help us address obesity, diabetes, health conditions like that.
The problem is the structural factors behind those. These health-equity issues are far more entrenched and difficult to treat. You can’t treat diabetes with a vaccine, right? You can’t prevent obesity with a mask. What you have to do with these things is you look at poverty, food deserts. You have to think about structural racism.
This is something we shy away from talking about, but it’s very important. And so those sorts of things are more foundational, and they’re not as easily remedied by a simple public-health response, but there are things that we can do.
In a sense it’s a job for the folks who are coming after you, but walk me through that.
We have a special unit called our Community Engagement Center, which is part of the Jackson Heart Study. And they did a lot of great COVID work. But now they’re able to divert and do more—can use these networks to address all of these chronic diseases, all these access-to-care issues.
And so it’s going to be a springboard that we can build on. We can build on what we’ve already had pre-built. Our lattice of connections is so much more broad. Hopefully we can expand it (further). One of the challenges with public health is we have to have partnerships.
One of the things that’s really been hard is that we’re asking the same number of people to do all these different things. Our staffing is lower (at MSDH) than it was two years ago. But we have a lot more work now.
The public-health workforce is far too denuded. It’s like building a road: you can’t suddenly drop money on a community and say “hey, I want a road in two weeks.” It takes years of planning. It’s the same thing with public health. It takes years of planning to make sure you have the structure.
Something that struck me in speaking to folks who have been successful—the team in Jefferson County, for example—was that these were usually community partners with whom MSDH had a prior relationship. And the partners had a prior relationship with the communities that they were supposed to be reaching.
You’re exactly right. It’s about having those trusted relationships to begin with. You really can’t build trust in a crisis. You have to have it built out before. Having those communication lanes was incredibly important.
Hopefully we will expand upon areas where we have a lot of good connections. Especially in the Black community, with barbershops and churches and other health-care coalitions. We’ve got a whole bunch of stuff going on. We’ve also started something called the Health Ambassadors Program, where we have a collection of community leaders who join us for a monthly meeting and help us communicate messages out to their populations.
That’s really been a lot of fun. We also need to work more in the Hispanic community. We’ve made some good connections with the different advocacy groups, like the promatores, the community-health workers who are sometimes informal, sometimes paid.
There’s just great opportunities everywhere. We’ll try to push forward on them.
This interview has been edited and condensed for clarity.