An Engine,Not a Vessel: Place,Politics,and Health in the United States

Abstract

Social scientists often treat places as containers for social and economic phenomena that shape health outcomes. Yet this analytic practice conceals more than it reveals. Local governments in the United States should be understood as engines of both health promotion and stratification. As the contributions to this symposium suggest, governments not only occupy a formal place in the U.S. public health system, their decisions on everything from housing to transportation infrastructure can also have profound impacts on health outcomes. Local political economies likewise renegotiate the parameters of acceptable health interventions, public understandings of health disparities, and the status of population health as a public good. By illustrating these linkages, the authors here suggest important future lines of research on both the promise and limits of local health governance, as well as how the allocation of local political power shapes health disparities.

In one of the most racially segregated cities in the United States, even electricity appears to discriminate. Between 2009 and 2019, 68 Milwaukeeans died because of electrical fires in their homes. These fires disproportionately affected Black renters in the 53206 ZIP Code, which has been plagued by decades of government neglect and private disinvestment. Yet in a groundbreaking series of stories published in 2021, reporters from the Milwaukee Journal Sentinel showed that these fires were not merely the product of decaying infrastructure or distressed housing stock (Rutledge, Diedrich and Chen 2021). Rather, they were the somewhat predictable consequence of a series of low-profile policy changes that gutted the regime of rental inspection designed to identify safety risks. Beginning in 2011, a group of Wisconsin state legislators—a number of whom were landlords themselves—passed a series of bills that severely limited the scope of local rental inspection programs. At the same time, the City of Milwaukee, under pressure from landlords, rehabbers, and even some aldermen, began weakening its permitting requirements for electrical work. These fires—and the death they caused—were nothing short of policy tragedies.

And yet soon after the Journal Sentinel investigation wrapped up, the problem seemed to disappear from public consciousness. The state legislature did not budge on rolling back its preemption of tenant protections. While members of the Milwaukee Common Council vowed to take what action they could, two years later the Council remained mired in a legal quandary over whether new proposals for rental protections were, in fact, preempted (Rutledge 2023). The public attention that had briefly grown around the issue had all but dissipated. In the United States, a country where the role of government often remains hidden in plain sight, this is not at all uncommon. The work of city and county officials at everything from the prevention of overdoses and gun violence to the control of foodborne illnesses remains especially invisible. Nevertheless, US local governments remain essential—if deeply underresourced—players in the country's highly decentralized public health system (Trust for America's Health 2019). Not only do local governments employ the largest share of the US public health workforce (Jones et al. 2015), they shape health outcomes through policy decisions that cut across local policy domains as various as economic development, zoning, housing, transportation, and public safety. Despite brief flashes of public awareness, typically during health emergencies, the correspondence between local politics and public health remains submerged.

Confronted with this important but understudied set of relationships, the contributions to this symposium do something more than merely “bring local governments back in.” Rather than simply hunting for county- or city-level variation, the authors here make great strides in pushing us to think about the imprint of local governance on the policies, institutions, and practices that shape health outcomes (Willison 2025). In drawing these connections, the authors show us how local political economies renegotiate everything from the parameters of acceptable health interventions to public understandings of health disparities to the status of population health as a public good. Counties, municipalities, and special districts are thus not vessels filled by other contextual or compositional variables. They are engines of health provision and stratification. This perspective, I think, is essential for understanding local governments’ potential to advance or reverse gains in population health.

That Americans cannot see the imprint of local governments has not eclipsed the sense—equally appreciable in political rhetoric and scientific analysis—that “place matters” for health outcomes. Indeed, spatial analysis has been at the core of public health investigation since at least the late eighteenth century (Koch 2009). Geographic neologisms continue to abound; there are healthscapes and medigaps; food deserts and vaccine valleys; sick zones and wellness corridors. The notion that “a child's zip code should not determine her life expectancy” has become something of a chestnut. The wide diffusion of Geographic Information Systems (GIS) technology—no small contributor to these developments—has left the public health literature piled high with atlases of healthcare prices, maps of infant mortality coded down to the level of the census tract, and county-level indices of chronic diseases and life expectancy. This geomentality recently reached a kind of apex during the COVID-19 pandemic, when newspapers and government websites featured pandemic dashboards that showed daily geocoded rates of cases and deaths.

Geographic knowledge promises explanations that avoid the “individualistic fallacy,” in which health outcomes are treated as the product of individual choices or behaviors while ignoring critical features of the social or structural context (Subramanian et al. 2009). Space, as used in most social scientific accounts of health, is thus a “container” in which configurations of variables coincide and interact with one another (Agnew 2011). That infant mortality rates vary substantially across US counties might be attributed to a combination of locally specific concentrations of poverty (Mohamoud, Kirby and Ehrenthal 2021), local disparities in access to and quality of healthcare (Rauscher and Burns 2023), or exposure to pollutants (Woodruff, Darrow and Parker 2008). A raft of recent studies also investigates the role of spatial variations in political institutions and public policies in shaping health outcomes (e.g., Montez, Cheng and Grumbach 2023; Krieger et al. 2024).

Treating a place as a vessel has its advantages. Difference-in-differences analysis can isolate, in a quasi-experimental way, the effects of a state's decision to expand health insurance coverage on disease incidence and mortality. Mapping variation in the relationship between income and life expectancy across the United States holds the promise of identifying the bundle of policies or social formations that promote greater equity in health outcomes.

Nevertheless, these studies also have a way of black boxing the question of how local governments—or localized networks of state-society relationships—reshape the boundaries of public health. Cities, as Harvey (2005) suggests, are “not simply constituted by social processes, they are constitutive of them” (23). For example, by allowing for the absorption of surplus capital through infrastructure projects, the development of commercial real estate, and the expansion of labor markets, cities provide a temporary “fix” for crises in capitalist accumulation. In turn, urban governance decisions ranging from zoning to freeway planning can direct investments in ways that reproduce spatial inequalities. And when cities cease to provide this fix, new forms of spatial inequalities in health may emerge. At the same time, cities serve as a unique power resource for the working class in ways that may redound to movements for health equity. Most importantly, urban economies constitute choke points that workers can leverage in strike actions and where mass populations are drawn together in ways that lower the costs of mass gatherings, protest, and political organizing. Cities can also serve as models for policies that can reshape the social determinants of health, ranging from living-wage and paid leave policies to housing rights and basic income programs (Doussard and Schrock 2022).

Moving from urban cores to rural peripheries allows us to see another set of dynamics at work. Whereas cities allow for capital absorption through real estate and infrastructure, the governance of rural economies—centered on resource extraction, industrial agriculture, and (now declining) manufacturing bases—produces unique health disparities (Burton et al. 2013). Underinvestment in rural care infrastructure strains the provision of a range of health services (Miller et al. 2020; Planey et al. 2023). The governance decisions of rural counties—such as zoning policies that permit or restrict large-scale livestock operations—can entrench patterns of environmental degradation (Raff and Meyer 2022). Failed responses to the decline of rural economies––ranging from weak worker protections to policies that impede healthcare access––magnified rural health inequities health inequities (Case and Deaton 2020).

There are, then, good reasons to take seriously the proposition that places shape public health not as containers for social action, but as engines of social transformation. Shifting our vantage point, as the contributions to this symposium suggest, offers several opportunities for sharpening our understanding of the imprint of local governance on health outcomes.

One important implication drawn out in this symposium is that changes in urban spatial structure affect epidemiology not merely by altering the profile of risk but by shaping the state's capacity to manage it. As Sullivan and Strach (2025) demonstrate in their examination of the problem of waste accumulation, urbanization did not merely produce new vectors for disease, it generated new configurations of organized interests and expertise that—through their solutions to the problem of trash—remade the boundaries of the field of public health itself. As a policy idea, sanitation was a child of urbanization in multiple senses. Not only did nineteenth-century cities’ agglomerations of population and industrial production give birth to new vectors of disease, but new agglomerations of capital enabled the creation and expansion of new bodies of expert knowledge about how to manage the risk of disease outbreaks that could jeopardize production. Nevertheless, the credibility of sanitation—and of the new legions of sanitarians who sought to apply it to the problem of municipal waste—was not preordained. It resulted instead from a political struggle: experts had to negotiate tensions with business interests whose interests in sanitation efforts hinged on how those efforts affected commerce. Sanitation could only become a politically robust approach to waste removal—a “common carrier” in the parlance of political science—if it was good for business (and thus if the glow from the reformers’ haloes could be dimmed).

Sanitarians’ success also involved an alignment with, if not the cooptation of, other slices of the professional class that the wealth of cities and their educational institutions created. While engineers might have advanced alternative technologies and scientific concepts to solve the waste problem, sanitarians were ultimately successful at enrolling these experts in their own disciplinary project—which meant treating waste as first and foremost a problem of public health. And while the advance of sanitation techniques produced estimable improvements in the control of disease, the triumph of the sanitarians also entailed new forms of social and economic stratification. Scavengers—the small-time, often impoverished incumbents in the field of waste collection—were put out of business. Longstanding nuisance laws were of no avail to persons unfortunate enough to live at the edges of cities where new dumping grounds or crematoria were located. The utilitarian calculus of sanitation brought with it new forms of power for local governments that altered the urban landscape itself.

The contests over the meaning and methods of sanitation mapped by Sullivan and Strach (2025) have continued to the present day, shaped by changes in both urban political economy and knowledge production. In recent years, a growing number of cities have attempted to realign their sanitation departments around the goal of minimizing rather than managing waste, and new contests over the principles, practices, and politics of waste removal have begun to take shape. However, as new conflicts over the notion of “zero waste” cities are resolved, this transformation in urban waste regimes will likely have significant consequences for “global systems of material extraction, production, and consumption” (Pollans 2021, 3).

The stakes of local political conflict extend well beyond the question of which experts should be heeded and which policy instruments employed. Rather, at the heart of these battles is the question of whether public health is, in fact, a public good at all. As early 20th-century urbanization reached a crescendo, this question remained a highly unsettled one. In their battle to construct public parks, visionary planners like Milwaukee's Charles Whitnall had to argue that privately owned (and fee-for-service) beer gardens and oases at the city's edges were fundamentally incompatible with workers’ ability to live “in physical and mental health” (quoted in Platt 2010, 780).

Rather than taking for granted public health's status as a public good, Jarman et al. (2025) analysis of mosquito-borne diseases allows us to ask questions about the extent to which—and the conditions under which—public-health functions are truly non-excludable. The structure of local governance in the United States is crucial to answering this question (Burns 1994). In the United States, the proliferation of narrow, functionally specific special districts has the potential to transform local public goods—including mosquito abatement—into private club goods. In the absence of state matching funds, high variation in property taxes that finance these geographically fragmented districts has the potential to deprive residents of areas with fewer taxable resources more vulnerable to infectious diseases. When the members of mosquito control boards are elected in low-turnout elections, they are perhaps especially prone to capture by economic elites in ways that reinforce these disparities. To be sure, consistent with a growing (and nuanced) literature in the field of public administration, the authors do not suggest that the proliferation of special districts invariably produces club goods (see e.g., Goodman, Leland and Smirnova 2021). For example, a redistributive formula for allocating state aid to lower-resourced jurisdictions might well take care of this problem. In a context of decreasing fiscal support for support public health—to say nothing of a political assault on scientific expertise at both the state and federal levels—it seems likely that Florida's unequal mosquito abatement regime will endure.

As the case of mosquito abatement illustrates, not only can the structure of local governments affect the excludability of health-related goods, so too can intergovernmental relationships—in this case fiscal relationships. Studying the relationship between place and health requires careful attention to these dynamics. While political scientists have in recent years made significant advances in applying quantitative tools for analyzing local government ideology and partisan politics first pioneered in Congress and then in state legislatures—tools that have the potential to advance the study of local variation in public health—there is a great need for caution here (de Benedictis-Kessner, Jones and Warshaw 2025). Local governments in the United States cannot be treated as structurally equivalent to the states or the federal government. Under the nineteenth-century doctrine of “Dillon's Rule,” their discretionary authority is often highly circumscribed by state law. In recent years, state policy preemptions have significantly inhibited many local governments’ ability to protect public health via everything from wages and workplace-safety regulations (Pomeranz et al. 2019). Additionally, states can set tight limits on local taxing and spending. On the expenditure side, states can determine local expenditures through policy mandates, whether funded or unfunded. On the revenue side, states both establish limits on tax sources and rates and, in some cases, supply significant shares of local revenue in the form of tax turnbacks, general revenue sharing, or targeted aid programs. Where these aid programs play a significant role in local budgets, state underfunding—especially likely during economic downturns given the procyclical character of state budgets—can result in the strangling of local public health capacity (Kass, Rocco and Romano 2021). State and federal policies on municipal incorporation and highway aid can also reshape the spatial distribution of metropolitan populations in ways that constrain local revenues. In sum, while local governments can clearly shape health outcomes, their choice parameters are set—often invisibly—by decisions at the state and federal levels.

Constraints on local choices about public health have not, of course, prevented local governments from innovating in this domain. Even census tracts, the basic units of analysis that allow for national analyses of health outcomes, were first pioneered in the City of New York as “sanitary areas” for the purposes of public health planning (Krieger 2006). Local governments possess any number of unique characteristics that might help to drive this innovation. Institutionally speaking, cities and counties are rarely constrained by the same kind of veto points, particularly bicameralism and supermajority requirements, that can frustrate policy change at the state and federal levels (Diller 2014). The proximity of local governments to distinctive health risks, combined with the relatively high levels of public trust they enjoy, may also enable local officials to serve as trusted messengers on public health crises in a way their state and federal counterparts, in whom public trust has cratered in recent decades, cannot.

Local governments’ “messenger” role matters because population health is the result of large numbers of people taking voluntary actions like getting flu shots, practicing safe sex, and refraining from driving while intoxicated. The conditions for overcoming these collective action problems are not only material (free and widely available vaccines, condoms, and convenient public transportation all reduce the costs of collective action); they are cognitive. Individuals who take costly actions must receive credible signals that their individual action is pivotal to the outcome and that there is a (usually normative) reward for their participation. To the extent that local officials enjoy greater trust and access to local populations whose actions are necessary, they are the ideal messengers for public health communications. This is one of the more profound implications of De Paula Moreira et al. (2025) work on racism as a public health crisis. Drawing on a growing body of research, local government declarations that racism is a public health crisis had agenda-setting effects that cut across jurisdictional boundaries and reverberated across metropolitan media markets. To be sure, these declarations were not consistent across local governments (following a predictable partisan pattern) and did not have a lasting effect on media coverage. Yet these findings must be placed in context. Local policy declarations of this sort constitute a relatively low “dose” of government action. Thus, the scale of their short-term agenda-setting effects, and producing an estimable increase in the salience of racism in local media, are impressive. They also signal that regardless of the federal government's policies on public health or the perlocutionary acts of federal officials on the question of racism, mayors and county executives have the potential to serve as trusted messengers in ways that cut against the grain in a nationalized polity. In a deeply polarized informational environment, succeeding at this messaging role will be more costly. But the opportunities and imperatives for using the United States’ thousands of local “bully pulpits” remain.

As with other public health functions, local governments’ ability to serve as trusted messengers for public health campaigns relies on their governing capacity. Yet the concept of capacity, as Kuo and Kelly (2025) show, has long been an elusive one for political scientists and public health researchers. In the years that preceded the onset of the COVID-19 pandemic, the United States ranked near the top of the most widely available indices of pandemic preparedness—a ranking that relied on a definition of capacity that was heavy on formal and procedural elements: testing facilities, protocols, professional accreditations, and so on. The analytical utility of that ranking disappeared within a few short weeks after the onset. While the federal government was eventually able to mobilize the delivery of public health resources to local governments, administrative and fiscal disparities across those jurisdictions, not to mention the sharp partisan divides that ultimately engulfed pandemic perceptions and behaviors, led to strikingly different patterns of infection and death across the United States. Administrative structures and protocols, it would seem, are only as good as the fiscal regimes and political ecosystems in which they live.

As Kuo and Kelly (2025) suggest, another reason rankings of the US may have gotten it wrong was that they failed to take into consideration the variation in the state's informal capacities, or its ability to coordinate action across both jurisdictional barriers and across the state-society divide. When governments had strong pre-existing community partnerships—often built through prior rounds of disaster response—they proved far more capable of communicating public health measures, ensuring compliance with health protocols, and performing outreach to vulnerable populations. Strong relationships with non-state actors (e.g., businesses, schools, faith groups, and hospitals) helped counties undertake awareness campaigns, ensure compliance, and reach vulnerable populations. Local governments’ ability to activate this informal capacity is of course deeply intertwined with the character of local civil society itself, as studies examining early-stage voluntary compliance with pandemic measures have shown. Yet, importantly, the informal capacity Kuo and Kelly (2025) describe is not reducible to high levels of social capital. Rather, even where high levels of social capacity exist, they must be activated. This is more easily done if governments have strong, existing relationships with multiple, cross-cutting audiences. The cultivation of these state-society partnerships may also make public health agencies more resilient to political attacks—a subject of increasing importance in the United States, and one on which cross-national comparisons may provide useful insights (Rich, da Fonseca and Bower 2024).

The ability to cement state-society linkages is by no means unique to local governments. Nevertheless, of all units of government in the American federal system, entities like cities, counties, school districts, and regional intergovernmental organizations are often ideally situated to develop the informal capacity Kuo and Kelly (2025) describe. Not only do these entities account for the vast majority of government employees in the United States, but their elected leaders are often positioned in the center of local social and economic networks through which information and incentives flow. Even when they lack extensive resources or formal authority, these leaders have an extraordinary potential to catalyze collective action in ways that have national implications, especially when other levels of government are incapacitated or are actively undermining efforts to carry out key governance tasks (Rocco 2025). Still, it is worth emphasizing that local governments do not operate in relative isolation from social and economic forces, or from one another. Political attacks on scientific guidance and health research in Washington have unavoidable reverberations in city halls and county buildings, as does the retrenchment of federal aid programs that support these activities. Perhaps most distressingly, the last decade has seen an exodus of local and state public health workers in the United States which further cuts to the already highly austere public health system will only accelerate (Leider et al. 2023).

It seems almost unavoidable that in a complex, far-flung polity, local governments would, to varying degrees, play an important role in promoting and stratifying population health. Still, the degree of promotion or stratification is contingent not only on local governments’ place in the wider regional economy and the federal system as a whole but also on the local allocation of political power. While the question of “who governs” is a perennial one in the study of local government, treating the place as a container for action abstracts away from this question, making it difficult to understand both the reasons for concentrated health inequalities as well as what Jones (2024) calls “ripples of hope” for addressing them. Local governments will bear the brunt of the major health challenges of the next several decades, such as population aging, climate change, rising rates of mental illness, and long-term housing insecurity, to name a few. Whether that is a cause for optimism or doubt is at its root a question about power and one to which political scientists and epidemiologists alike should urgently attend.