Advancing Public Health Through Community Partnerships: Dr. LaMar Hasbrouck, Managing Director of DLM LLC

Lindsey Smith

Hi, I'm Lindsey Smith, welcoming you to Raise the Line with Osmosis from Elsevier, an ongoing exploration about how to improve health and healthcare.

At a time of unprecedented challenges for public health professionals and programs, we're turning today to someone who is dedicated to advancing public health and inspiring the next generation entering the field. Dr. LaMar Hasbrouck is managing director of the consulting firm, DLM LLC, and brings a deeply informed perspective as a physician and leader in public health to his clients.

From being a CDC disease detective, to leading the Illinois Department of Public Health to serving as executive director of National Association of County and City Health Officials, Dr. LaMar, as he's known, has contributed to major global health initiatives, including the WHO's polio eradication program and the U.S. President's Emergency Plan for AIDS relief. He also emerged as a national authority on public health during the COVID-19 pandemic, frequently sharing insights with major media outlets.

I'm looking forward to exploring his personal mission to inform and inspire to improve human health, and the insights he brings to advancing public health. Thank you so much for joining me today, Dr. LaMar.

Dr. LaMar Hasbrouck

Thank you so much for being with us today.

Lindsey

So to kick things off, I'd love to hear more about your personal journey. What first sparked your interest in medicine?

Dr LaMar

Well, Lindsey, I think the seed was planted growing up.  I grew up in what I would call a deficit community. So it's one that had food insecurity, lack of access to health. We didn't have normal doctor appointments, kind of preventive appointments, things like that.

And I think that kind of planted the seeds so when I was fortunate enough to get into college and I get accepted to Berkeley, once I got on campus I thought, shoot, I'm here, I may as well aspire to do something large. And then I kind of reflected back to my time growing up and some of the deficits and I thought, you know, I could probably commit myself to being one of those persons to gain the skills, to gain the education so that I could kind of give back to communities like the one that I was in growing up.

So that's kind of what planted the seed. And when I got there, it wasn't really so much a physician as it was any type of health care professional or any type of health professional. And so that's kind of what started it for me.  I think of a lyric in a Kanye song that says, “everything I'm not made me everything I am.” So I think for me, growing up in that deficit community kind of led me and propelled me to this mission to try to be something more and to try to address some of those deficits.

Lindsey Smith

Thank you so much for sharing that origin story. I think they're always so powerful to understand what got you started in the field. I also had a sister that went to Berkeley, so go Bears. 

Dr LaMar

Go Bears!

Lindsey
Your story started in medicine and then it kind of led you into public health. Can you talk about what drew you in specifically to public health and what's kept you there?

Dr LaMar

Okay, so again we go back to Berkeley and I played football at Cal so that meant having a lot of fun but it also meant having a hit on my academic performance. So when I finished my undergraduate years at Berkeley I didn't have a  very strong GPA and I thought, well, how can I impress medical school admissions committees about my candidacy for medical school? And Berkeley has a very, very top rated school of public health. So I said, well, maybe if I stop by and try to get this master's in public health, I can beef up my GPA, beef up my experience, take some other courses, and be a much more attractive candidate. So that was my introduction to public health.

And while there, I learned, wow, here's an opportunity to have a macro impact, not just seeing patient by patient, but seeing communities by communities and really addressing the community as a patient, either the neighborhood or the zip code or the city or county. Public health struck me as an area of interest because it's kind of working on the ecosystem level and really addressing some of those drivers and conditions that lead to health, you know, the upstream or the in-stream approaches. 

We talk about determinants of health oftentimes and most people mention that term in the context of social determinants of health, income, education, but there's also behavioral determinants. There's environmental determinants, there's medical determinants. So, you know, it just kind of gave me that exposure and it codified my commitment because I thought, this is what I call a splendid profession, public health, because it has so many opportunities for impact. You work with a multidisciplinary staff...you've got your health economists and sanitarians and epidemiologists and all kinds of different folks. I'm working in a very, very dynamic field. So that's kind of what lit the fire for me in terms of my interest of public health.

Lindsey Smith

That's really interesting. I want to ask you a question that we've gotten before from some of our listeners about the differences between healthcare, public health, population health, and population healthcare. Can you help us distinguish those terms?

Dr LaMar

Yeah, I'll give it a try. You know, it kind of depends on who you ask and where they sit in this enterprise. But I'll tell you like this. I worked recently for a very, very large county health system in Cook County, Illinois and they are a publicly funded health care system with hospitals and clinics and things like that. And the county executive would often refer to it as public health.  I would often try to correct her or staff and say, no, this isn't public health. This is publicly funded health care. This is safety net health care. So, I think even at the highest levels, folks get it confused, so I appreciate the question. 

Let me give you kind of my paradigm to looking at it, and this might help early career folks especially to look at it. Look at the individual, yourself, your family members, mom and pop. At the individual level, when something happens to you -- you get an injury, you have a symptom or illness or something -- you go to pursue healthcare. You go to a clinic or hospital and you're being treated for that condition, for that injury. You're being diagnosed, you're being treated, given medicine, x-rays, that's healthcare. Healthcare is about the business of caring for individual health. In that system, you will see folks like physicians and pharmacists and nurses and allied health professionals and radiology techs. That's health care at the smallest level, the individual level.

Now, if you broaden that circle a little bit and you talk about the types of people that seek health care, let's just say someone that has diabetes or someone that's pregnant, we can group those folks into a group or a population of patients. We refer to that often as population health care or population health management. That is you're managing like patients. So every person with diabetes should get an eye exam, a foot exam, should be testing your blood for sugar and things like that. So you're kind of taking a population health approach for a group of specific patients that share a trait or a risk or maybe high-risk diabetic patients who are hard to treat and you're applying kind of a system of care to them, something that everybody gets routinely and then you're kind of managing them.

So that's population health care, sometimes referred to as population health management. 

Now we get to public health. Public health is something different altogether in that you're not doing one-on-one patient care. You're really working again at the level of the community. You're saying this city or this village or this town has rates that are very high in high blood pressure, smoking rates, things like that. So you're working really more at a macro level. You're really trying to address those determinants of health. Also think about vaccination campaigns and tobacco prevention campaigns. You're really working at a much, much larger level. So you're really into things like mobilizing the community around health prevention or disease prevention and health promotion and protection. So, measles and foodborne illnesses at restaurants and the Zika virus, you know, when that was happening, things like that. So, it's a much broader lens.

Because you're dealing with things like water and food and communicable diseases and disease outbreaks, you have a different level of professionals. So, you might have sanitarians, you might have epidemiologists, you might have statisticians, you might have some physicians and nurses, typically you do, but you'll have a much broader group of  people that are looking at the environment and looking at tick-borne diseases and things like that. So it's much, much broader. So that's public health.

Then if you look at the biggest aggregate level, that's where you kind of get into population health. Really, you're talking about many actors working in a very large ecosystem and you're talking about really looking at the health outcomes of populations in the aggregate. So you talk about things like health indicators around health outcomes and distribution of health outcomes by saying, you know, this city has the highest rate of hypertension or, you know, Latinos in this community have the highest rate of accidents. So you're really looking at things around life expectancy, health expectancy, death rates, disease rates, trends at the largest level and you're able to do that and make comparisons with other cities or villages or whatever. So that's kind of population health. 

Unlike having the doctor and the nurse or having the sanitarian or the epidemiologist, in population health you have a lot of actors. Some of them are health related, some of them are not. Some of them might be businesses, it might be social services, it might be food banks. All of that contributes to really the health of a said population and that's what we mean by population health. So that's one framework to look at the differences.

Lindsey Smith

That was a really helpful breakdown. Thank you so much for sharing that with us. I want to ask you from where you sit, what do you see as the most pressing health challenges facing communities today?

Dr LaMar

You know, I thought a lot about this and you may be surprised because even though I am a physician and a public health practitioner for some 30 years or so, I'm going to give you an answer you may not expect. That is, I think the most pressing issues are number one, I would say noise. What I mean by noise is I mean not only just the environmental noise and the humming that goes on with kind of noise pollution, I'm really talking more about social noise. I'm talking about really the constant bombardment of information because I think that constant bombardment of information leads to lot of distractions, it leads to chronic stress, we're always comparing ourselves to other people or other circumstances. I think it leads to spiking cortisol levels, that's a hormone that's related to stress, which relates to cardiovascular disease. I think there's what I would call a mental paralysis or kind of a stalemate paralysis that occurs because there's so much going on that it's kind of hard to know which way to go. You know, so there's so much confusion that it kind of leads to inaction. I think with inaction, folks really don't know what to do in terms of addressing their health. So I think that that's probably number one in my mind. 

Number two is related and I would term it as kind of insulation or social isolation. Some people call it cocooning when you do it on purpose or just this asocial behavior. I'm not talking about antisocial, but asocial. That is kind of going inward, spending a lot of time inside because of all the modern conveniences, you know, be it your Grubhub or your Uber Eats or everything you can do from your phone. You don't have to go outside to do anything.

We learned a lot of these behaviors during COVID, but I think we haven't really broken a lot of them. I think it leads to lot of loneliness for a lot of folks. I think it also reinforces a very dangerous, sedentary lifestyle, which we know can lead to higher rates of obesity and diabetes and high cholesterol and heart disease, as all those symptoms together can be categorized as something called cardiometabolic syndrome. It's a condition that increases your risk of having bad outcomes, usually cardiovascular outcomes. That's that sedentary lifestyle that I believe is related to this more insular kind of social isolation that happens. 

As a result of these two things, which are related, I think, I think we have higher health expenditure. That is, we're spending more on our health. We have a kind of a premature death and disability rate. Now, I'm going to say disability because it is known or widely appreciated that although we're living longer -- our lifespan or life expectancy is going up and up by the decades -- we're also living sicker. So there's a lot of disabled people who are not living very well, they're living long, but they're not living well. 

So those are the two things I would say noise and this social isolation or insulation that's happened.

Lindsey Smith

Those are really great points and important ones. You mentioned social noise and social isolation, and it kind of ties into something I'd like to also get your take on. So why is it so hard for individuals and communities to achieve optimal health outcomes, even though in a sense we kind of do know what works?

Dr LaMar

Yeah, you know, that's a conundrum. I gave a talk recently called Health is Hard. One of the things I tried to emphasize to my audience is this whole idea of distractions. I explain it to my 15-year-old son because he likes to give me a hard time about my age and thinks I got one foot in the grave and he's got his whole life to live. So I tell him, look, you don't know what could happen because every single day, each one of us are trying to navigate through kind of a gauntlet of stuff. It's distractions, it's social media feeds, it's our own lack of commitment or discipline. It's just very, very difficult. 

I think on top of that, you have a lot of mistrust. We saw this certainly during the pandemic where a lot of my colleagues in public health were giving messages and guidance and a lot of them were looked at as the bad guy, were the target. A lot of them either resigned or actually got fired, got pushed out of office just because folks didn't want to hear what they had to say. That's kind of the skepticism or the mistrust that I think is a challenge.

I think there's also a challenge related to health literacy, cultural competency, because we know folks that have the worst health outcomes are usually those who are the least educated, those who are black and brown. So, health literacy is very important because when you're trying to give the message or try to give the guidance, understanding the concept, understanding what needs to be done and how often is so important. 

So I think those things are very, very front and center when it comes to achieving optimal health. It starts at the individual level, but it’s also important to understand kind of the context or the ecosystem you live in. If you don't have a lot of pro-healthy opportunities, activities, consistent information, supports, then it's going to be very, very difficult to achieve your optimal health.

Lindsey Smith

I appreciate how you clearly frame that. You mentioned navigating distractions, mistrust, and health literacy, and I think it's a good reminder for all of us that some of these solutions aren't just clinical.

You mentioned the pandemic. So I want to of come back to that a little bit. During the COVID pandemic, you coined the term “know-it-all-ogist”. Can you tell us what this term means and how does it relate to the dangers of misinformation and health?

Dr LaMar

Thank you. Yeah. So this is what we all know. We know that when the pandemic happened, it activated kind of this unprecedented brain power across the globe. We were all kind of moving around trying to either solve the problem, trying to solve the riddle of COVID, the pandemic of the novel coronavirus. That activated a lot of folks trying to develop, you know, the vaccine and test the vaccine and roll it out and so many different mitigation strategies --  you know, cover your cough and stand six feet apart and stay inside -- there was so much going on. So there's this fury of brain power, I would say.

Unfortunately, in addition to all the folks that were hard at work that had knowledge -- like the vaccinologists and the immunologists and the virologists and the epidemiologists -- we had scores of social media mavericks or influencers who took to their keyboards and started just saying anything and everything on their platforms. That's what I came to call the “know-it-all-ogist”. These are folks who have an opinion – which if fine, everybody has an opinion -- but every opinion is not an informed opinion.

So what would happen with this flood of “know-it-all-ogist”, there would be a lot of disinformation that is intentionally misleading folks, misinformation that is kind of unintentionally misleading folks because you don't have all the facts or you don't quite understand them, and then there was this diluting effect that happened because when you have so many messages out there, once again with the distractions, it dilutes the science and the guidance and it makes it very, very difficult for folks to navigate through that information.

So, it made it made things difficult and undoubtedly it led to scores of more folks that were injured, harmed and maybe even died as a result of COVID because they got a hold of some bad information.

Lindsey Smith

That's a great way to describe the issue and painfully accurate. As we kind of look back on your experience with the COVID pandemic, what strategies have been most effective in managing a public health crisis?

Dr LaMar

The strategy that I found in my career that's the most potent strategy for managing any public health emergency or urgency has been timely communication. Not just timely, but timely, honest, transparent, accurate, and consistent communication. You have to lead with empathy, but you have to accelerate those messages through the speed of trust.

We have a whole thing in public health called public health preparedness or emergency preparedness where we do tabletop exercises and try to figure out where to have a cache of antidotes and things like that. But this is really another type of preparedness. This is really the everyday building of the relationships with the communities that you serve because you’ve got to build that foundation of trust so that when the stuff hits the fan, when the emergency comes, you can trade on your relationship. You can trade on the trust.

It's almost too late to do it when the emergency is hit and so hopefully, you'll have a trusting relationship where you have been there for the community, educated the community, shared with the community, learned what they have to teach you, and built a trust so that when something happens, you can trade on that and they can really believe the communication that you're sharing is the best you have. So, that's one of the strategies...what we call crisis communication. Not necessarily being first, but making sure you're consistent and you're accurate. 

I would say the other two things I would emphasize as a strategy is credibility. That is, as a public health leader, you really have to lead by example. So if it's a vaccine you're advocating for, make sure you're taking the vaccine. If the water is clean to drink, make sure you're drinking a glass of that water. You know, show up, follow through, be proactive. So you're trading again on trust, you're trading on credibility.

Then the last thing I would say, certainly not the least, is humility. I think it's important to try to grow the sense of partnership. Yes, you're the public health expert or the medical expert, but folks in the communities are also experts as well. They're experts in their lived experience. They're experts in what's happening to them. They're experts in kind of the early signs of what they saw and observed, what the resources are, who are the key leaders you need to talk to. So to partner smartly with the community takes a certain amount of humility.

I think if you are humble, if you're credible, if you're giving them the best information that you have and not over promising, I think those are kind of the tenets that help you get through managing a public health crisis. There might be other antidotes and things to do, but it's all about how that information is going to be received and for how long. That really is about trust to me.

Lindsey Smith

Yeah. I think it's interesting to hear what goes on to managing a public health crisis. I really liked what you said there about working to build that relationship before the crisis happens, and I think that's a really important point to circle back on.

So, I want to ask you about the many changes that we've seen in public health funding and get your perspective on that, especially given the shifts we've seen in recent years.

Dr LaMar

Yes, so it is a subject that is disappointing for many in public health because the federal funding has been very important in keeping public health afloat. What most people don't know about public health, unlike healthcare or population healthcare, is that there's no profit model. There's really no margin. So public health is funded uniquely by the taxes of whatever that village or city or county is. They get money there, and then there's the state that they sit in and the state provides money as well and then as your question gets to, the federal funding comes in and helps also. 

But it's not seamless, it's not consistent. It's often what we call categorical funding, which is the federal government -- in most cases we're talking about the Centers for Disease Control and Prevention -- they're going to give different smaller municipalities or cities money, but it's not just money you can use for your public health, it's money you must use for this specific thing. You use it for, just  Zika, or you gotta use it for STD prevention, or you gotta use it for whatever. So it's not very flexible funding, and obviously if you're running any business, you wanna have flexible funding because it allows you to respond to new threats or new emergencies and things like that. 

All of that said, with the new administration, there will be less and less federal dollars going to local public health. My prediction, and in fact my hope, is that as a result, that at the municipal level, that is the city and the village and the county, and even some states, will be more innovative and more creative in how they identify sustainable funding. That they will be more committed to prioritizing public health funding and not just feel like, we're going to get 50 percent of our budget from the federal government, so we're good. We can use our state money or our county money to do something else. That they'll be more collaborative in working with the healthcare partners. 

Again, healthcare partners, that's a different business model. Many of them make a profit. Many of have a margin. Many of them, or all of them, are responsible for something called community benefit, that is partnering in ways outside of the hospital to benefit the community. Those are opportunities that they'll collaborate more with the philanthropic community and investors. There's a lot of investors that have nothing to do with health, but that will invest health for the community in which their business sits. So the Home Depot's or those big box stores, the Targets and whatnot that are in communities...they could smartly invest through a number of different vehicles, one being something called social impact funding, where they lend money or give money for you to improve health outcomes.

So, what I'm hoping is that as the federal funding dries up and is used more and more for what I call surge public health emergency -- something that happens like a pandemic or something else where the local health departments need extra money that they didn't have, that other than that, in funding their own federal priorities – that local municipalities will shift and take this opportunity and say we need to figure out how we can be more sustainable. 

I wrote a paper not long ago that showed that many of the local health departments relied on the federal funding for up to 60 percent of their budgets. So that means that if it's inflexible, if it's inconsistent and you have 60 percent of your budget there, that's not very smart. I've always thought that was kind of foolhardy for many, many years and I've tried to address it in the places that I've gone. But I think that I am definitely a proponent of kind of activity-based budgeting, prioritizing local public health, and assigning the money for the priorities in that locality in terms of what public health threats are in a way that's sustainable, that's built into the county budget so that local counties and municipalities don't have to always depend on a very inconsistent source of federal funding.

Lindsey Smith

I appreciate you breaking that down. It's helpful to hear how you're thinking about the future and certainly a lot of opportunities on the state level or for the social impact funding that you mentioned.

So, in today's audience, we have a lot of students and early career health professionals tuning in. What advice do you have for them as they face today's challenges and work toward a meaningful career in medicine?

Dr LaMar

Well, you know, I think that I still consider medicine and the health professions as a splendid profession. If you practice medicine, you're going to probably specialize even as a family doctor or an internist, which is my background. You're going to be seeing patients one by one by one. That is a great profession. People spend 30, 40 years doing that. That's great.

In public health, you'll be looking at a broader range of challenges, broader range of opportunities. We call it a multidisciplinary profession because you're working with folks with other backgrounds, not just medical or health, but other backgrounds as well. So that's an opportunity. 

But whatever you decide to do, I would say my most direct advice would be make sure you're doing it because you love doing it. Don't do it because your mentor did it. Don't do it because your parents wanted you do it. Don't do it because your parents did it. Make sure you love contributing to society, to the community, through a health professional lens.

If it's medicine or if it's public health, that will give you more of an ability to sustain in it and to not be burnt out. We have a lot of physicians nowadays that are burnt out. They're tired. They don't have any joy in the profession. I think that starts with kind what is your intent? What is your “why” for going into the health profession? So make sure you ask yourself that first. If you can tick that box, then I think there's plenty of opportunity for you.

Lindsey Smith

Such grounded advice. Thank you so much for sharing that with our audience. Before we wrap up today's episode, is there anything we didn't cover that we should have?

Dr LaMar

You know, the one thing I would add is, when you're talking about the importance of community engagement, I want the young professionals to know that that is important, but more important than engaging the community or community engagement is something I call community ownership. That is being in a position where you're not the keeper of all the knowledge and the solution and solutions, but you're kind of a partner. Because I think when you can transfer knowledge, when you can direct investments and resources, most people will do the right thing for their communities. They just have to understand the value in it, the relevance of it. So, you know, try to be in the business of asking yourself how can you build or help communities to build a culture of health within their culture, within their family starting at home, you know. That's one thing.

The other thing I would say, is that as a health professional, it's so important to try your best to walk the walk. Try to strive to be a health professional that not only gives advice and guidance, but lives by that advice and guidance. Because I think sometimes your patients will see a lot more in you than what it is you're telling them to do because if they look at you...it's kind of like trying to go into a barber and your barber's got a really jacked up haircut, you know, and you're going to sit in the chair with very little confidence because he doesn't look right. He hasn't lined himself up, so to speak. So, it's that kind of thing.

So those are just some things that I like to live by and just take the opportunity to share with the up and coming generation of healthcare professionals.

Lindsey Smith

Really great reminders as we wrap up this episode to build a culture of health and to live by example. Thank you again for joining us today, Dr. LaMar, and for sharing your experience with our listeners.

Dr LaMar

Thank you for having me. It was my pleasure.

Lindsey

And that brings us to the end of today's episode of Raise the Line. A heartfelt thank you to Dr. LaMar for sharing his wisdom, his passion for service and his unwavering commitment to strengthening public health. His perspective -- shaped by decades of field work, leadership and global impact -- offers grounding insights at a moment when the world needs it most.

I'm Lindsey Smith. Thanks for checking out today's show. Remember to do your part to raise the line and strengthen the healthcare system. We're all in this together.