The Intrinsic Relationship between Local Politics and Public Health

Abstract

Our symposium brings to bear novel theory and rigorous empirics on a key topic: the local politics of public health. As a field, urban and local politics has made critical developments in our understanding of social inequality and its implications for democracy. Many social policy components and structures studied in local politics are known as the social or structural determinants of health—high level systems including the built environment and local policies, that have the greatest influence on individual and public health compared to any other factors ( Marmot et al. 2008). Yet, urban and local politics has not thought of its contribution to our knowledge of public health directly, despite studying these very systems that overwhelmingly contribute to the health and wellbeing of populations.

Local Politics and Public Health

Our symposium brings to bear novel theory and rigorous empirics on a key topic: the local politics of public health. As a field, urban and local politics has made critical developments in our understanding of social inequality and its implications for democracy. Many of the social policy components and structures studied in local politics are known to the field of public health as the social or structural determinants of health—high level systems including the built environment and local policies, that have the greatest influence on individual and public health compared to any other factors (Marmot et al. 2008). These social determinants of health also greatly influence outcomes in public health responses to salient events, like pandemics (Trounstine and Goldman-Mellor 2023). Yet, urban and local politics has not thought of its contribution to public health directly, despite studying the very systems that overwhelmingly contribute to the health and wellbeing of populations. By contrast, public health scholarship often omits the role of political conditions in shaping these consequential, structural determinants of health (Greer et al. 2017; Michener 2023).

In these ways, there is much public health can learn from local politics, and local politics from public health. Bridging the two fields to generate a local politics of public health will deepen our explanations of key features of local politics and policy, with important implications for public health. This includes the democratic dynamics of structures and policies that affect public health—including the organization of local public health agencies which has been broadly understudied—and local jurisdictions’ decisions and dynamics regarding conceptions of public health.

Public health problems are such because they necessarily affect all citizens. Examining the democratic dynamics of local structures and policies that affect public health, and conceptions of public health not only improves our knowledge of the functioning of local public health but informs why local public health may be developed for some as opposed to all; what may be conceived of as local public health, for whom, and why; and the policy feedbacks of such dynamics.

This symposium brings together scholarship on the local politics of public health to begin to answer these questions. This introduction offers a framework for a research agenda around the local politics of public health, by reviewing the state of the literature across public health, health politics, and local politics. As American democracy precipitously declines (Bright Line Watch 2025), and unilateral executive actions undo foundational federal public health capacity (D. P. Moynihan 2025), the role of local public health, and the relationship between local politics and public health, becomes ever more consequential.

Structures and Policies that Affect Local Public Health

Health politics and policy scholars have long developed a robust knowledge of structures and policies that affect public health (Carpenter 2010; Fox 2016; Hacker 2002; J. Lynch 2020; Starr 1982). Yet, the vast majority of this work focuses on national and state level policies, politics and governance. As the United States is a federated nation that (although indirectly) delegates responsibility for health and welfare to the states (see Article 10 of the constitution) ¹ we cannot contextualize American public health without understanding vertical or federated relationships. However, given the emphasis on subnational relationships in the responsibility for health and welfare (Bishai 2017), we must also have a rich knowledge of the horizontal layers across each level. To date we have very limited picture of the functioning of local public health from a governance, policy and politics perspective (J. Lynch 2023; Shipan and Volden 2008; Willison 2021). As local governments are creatures of the state (Dillon 1911), we propose two categories of local public health structures that may allow scholars to further interrogate the influence of horizontal arrangements within and across local governments, contextualized with vertical incentives. This includes: (1) direct public health domains—namely, local public health departments; and (2) indirect public health domains, or local governance structures affecting the social determinants of health.

Direct Public Health Domains

Direct public health domains include the structure of public health functions within a specific “public health agency” in a municipal context. The emergence of local public health agencies, known historically and contemporarily as “Local Health Departments” (LHDs), is one of the oldest developments in the formalization of public health as a field in the United States (Grogan 2023; Strach and Sullivan 2023). Not only did the development of LHDs coincide with the inception of the field of public health, but it also occurred in a key period in local politics: industrialization, or the literal formation of cities as we know them today (Dilworth 2003; Smillie 1955; Trounstine 2018; Turnock 2016). In many ways, the advent of industrialization allowed for the formation of public health as a field. New industrial developments such as roads, sewage, plumbing, and electricity, provided opportunities for American cities to protect public health, while deciding the physical distribution of coveted resources to do so (for whom) in their jurisdictions.

As Colleen Grogan chronicles in her 2023 book “Grow and Hide,” LHDs received an influx of funding from the federal government through at the turn of the twentieth century. Yet as LHDs developed, organized coalitions of professionalizing public health actors labored to establish LHDs to distinguish themselves from physicians (Fox 2016; Grogan 2023). At their inception, LHDs covered a wide variety of services—many of which eventually moved into other domains, due to political competition over service distribution as a tool for professionalization and rent seeking (Grogan 2023; Smillie 1955). Today, public health departments provide a narrower array of services, yet are still tasked with many essential duties such as childhood vaccinations (Lillvis, Willison and Noyes 2020; Sparer and Brown 2023).

Despite this development, we know surprisingly little about the functioning of LHD governance, regarding both institutional structures and power dynamics (J. Lynch 2023). The primary source of information on LHDs, the National Association of County and City Health Officials (NACCHO) tri-annual surveys, provides detailed information on what services LHDs provide (National Association of County and City Health Officials 2024). Yet NACCHO data has limited governance measures and does not examine the power dynamics of LHDs. Absent measures of governance and power, shifting trends in the authority or responsibility for various public health services over time is difficult to distinguish (Dahl 1961; Orren and Skowronek 2004).

While we do not know much about the governing arrangements and power dynamics horizontally of LHDs, what we do know, based on the robust health politics and policy scholarship on federalism (Beland, Rocco and Wadden 2023; Michener 2018; Shipan and Volden 2008), is that these direct structures and policies function through administrative decentralization. Administrative decentralization works vertically, transferring resources from higher levels of government to lower, delegating discretion over some policymaking and implementation to lower levels of government yet maintaining some mechanisms of accountability and transparency, across levels (Sellers and Lidstrom 2007). In a post-COVID-19 world, where local public health faces dwindling resources (Alfonso et al. 2021; Leider et al. 2023); local agency officials are regularly threatened as a result of far-right mobilization against science and the administrative state (Fraser 2022; D. Moynihan 2022); and federal public health agencies are experiencing active workforce cuts, threats, and unconstitutional closure from an unconstrained executive (Moynihan 2025), the relationships and reality of administrative decentralization are also changing. In these ways, exploring the governing arrangements and power dynamics of LHDs is an essential gauge of not only the functioning of local public health, but of democracy. Public health efforts to solve collective health burdens and mitigate inequity mirrors the essential pressure in democracies to balance civil liberties with human rights protections (Mariner, Annas and Glantz 2005; Willison et al. 2022). If accountability declines, does representation of public health problems in LHDs change? Why and when are local public health bureaucracies constrained, or not? Why may scope and autonomy of local public health change over time, and for whom, both communities and agencies, and to what end?

Indirect Domains of Public Health

The structures of indirect domains of public health are just as essential to understanding the local politics of public health as the direct domains. Indirect structures refer to local bureaucracies external to LHDs that provide services related to the social determinants of health. The social determinants of health are “…the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (U.S. Department of Health and Human Services 2020). This includes things like housing, education, access to greenspace and sidewalks. Other local bureaucrats and local government agencies take part in the provision of these essential services that have, in many ways, a greater influence on health outcomes across the lifecourse than the provision of any medical services (Lantz, Lichtenstein and Pollack 2007; Marmot et al. 2008).

An important tension omitted in public health as well as local politics literature is the relationship between the provision of public health services through indirect bureaucracies (vs. direct) and public health and political outcomes or conditions (J. Lynch 2023). Historically, many indirect actors at the turn of the twentieth century leveraged public health “concerns” to rationalize the development of exclusionary social determinants of health infrastructure—(see zoning, Trounstine 2018). This exclusionary foundation has remained in place (or been reinforced) in many places across the country, exacerbating inequity in local public health outcomes and local political dynamics (Du Bois 1899; Grumbach and Michener 2022; Michener 2023; Montez et al. 2020), with open empirical questions about the role of contemporary or evolving governance, policy, and political arrangements. For example, such indirect public health governance arrangements may allow actors to elide accountability for public health failures, if they are not seen as having authority over public health (Stone 1989)—such as the Flint Water Crisis (Trounstine 2016a).

While direct local public health governance is arranged through administrative decentralization, often with support from higher levels of government (albeit increasingly limited), most indirect domains of public health governing the social determinants of health are structured through political devolution to local political actors. Political devolution to local actors removes vertical levels of capacity and oversight, placing full responsibility for policymaking and capacity at a lower level of government (Soss, Fording and Schram 2008). In the context of local politics, even though states have the power of preemption (Shipan and Volden 2008), local jurisdictions are designing policies and carrying out services to their own avail and through their own resources. This includes many key social determinants of health such as water, sanitation, parks, sidewalks, housing, and education (Einstein, Glick and Palmer 2019; Mullin 2009; Nuamah 2023; Trounstine 2016b). This may create a conundrum of asymmetrical incentives for accountability, transparency, representation, and capacity, across the two types of public health institutions. Opportunities for corruption and challenges to democracy may be more common in indirect public health institutions responsible for key social determinants of health (Strach and Sullivan 2023), whereas direct public health structures may suffer from capacity constraints (Greer et al. 2019; Michener 2018; Sellers and Lidström 2007). Importantly, in the evolving second Trump administration, the complex administrative state of federal public health capacity has been explicitly targeted for dismantling, significantly hindering vertical accountability mechanisms, as well as capacity, for direct domains of local public health (D. P. Moynihan 2025). Even in the face of this urgently changing landscape, the scope, heterogeneity, and mediators of these relationships are widely unexamined.

Conceptions of Public Health

Just as there is rigorous scholarship on questions of public health structure and governance at the national and state level, there is also an abundance of research on why various issues may be defined as public health or not, and the influence of such definitions on political behavior (Gollust, Lantz and Ubel 2009; J. F. Lynch and Perera 2017; Oliver 2006; Stone 1989). Yet, our understanding of these issues similarly falls short at the local level. Based on our limited knowledge of public health structures and politics at the local level, and the unique and divergent forms of governance across direct and indirect public health domains from decentralization to devolution, we should not assume that local conceptions of public health and their influence function the same as those at the national and state level. Two important factors likely related to variation in local notions of public health arise from the ways in which both direct and indirect domains of public health are governed: (1) hyper-fragmentation of local political environments in the United States; and (2) racial and economic segregation in municipal contexts as a fundamental cause of public health disparities.

As formative scholars of political science and health politics have shown us, problem definition is influenced by the interactions between political incentives, power dynamics, and problem salience (Kingdon 1990; Schneider and Ingram 1993; Stone 1989). Of course, these are bi-directional relationships, but there is an important interaction between problem salience and the institutional structures of incentives and power. In local politics in the United States, local political environments are hyper-fragmented compared to peer nations. Hyper-fragmentation, whether in the form of local media markets, special district governments, overlapping local jurisdictions, or exclusionary zoning, creates unique power-dynamics across space and place in local politics. In these ways, what is defined as a public health problem may not only be very different from neighborhood to neighborhood or local government to local government within the same municipality, but conditional on the power dynamics arising from these embedded spatial arrangements’ relationships. How are public health problem definitions shaped across fragmented environments, and received by constituents?

Historically, notions of “collective” public health problems such as the spread of “disease,” were used as a gatekeeping mechanism to retain political and economic power for white Americans, restricting access to essential social determinants of health, for low income and racialized communities through geographic segregation and zoning (Burns 1994; Monkkonen 1988; Trounstine 2018). Necessarily, such definitions of public health were tied to an exclusionary conception of public health for whites and economic elites. This is where the spatial component of public health inequality in the built environment must be incorporated into our understanding of local public health problem definition and policy feedback (Dilworth and Weaver 2020; Michener 2019). In public health scholarship over the past three decades, “fundamental cause theory” emerged to explain why persistent differences in morbidity and mortality are seen across racial or ethnic groups and socioeconomic status, despite the “biomedical” causes of morbidity and mortality changing over time (Clouston and Link 2021). This public health scholarship seeks to “examine the actions of the powerful in securing health and avoiding illness as a core driver of inequalities” (Clouston and Link 2021). Yet all too often, such public health investigations are limited to disparities in the social determinants of health in a vacuum absent local politics, or the outcomes of local politics as opposed to the power dynamics driving spatial inequalities in the distribution of the social determinants of health (Marjory L. Givens et al. 2018). New local politics research is starting to investigate relationships between adverse public health outcomes across different groups, local politics, and conceptions of public health problems (Haselswerdt and Gollust 2023; Laniyonu and Byerly 2021; Michener 2023; Purtle et al. 2021; Trounstine and Goldman-Mellor 2023). What is the relationship between spatially embedded public health inequality and collective definitions of public health, or public health problem salience? How does problem salience of spatially concentrated adverse health outcomes influence political behavior, policy change, and governance?

Local Politics of Public Health

The articles in this special issue begin to address these key questions to establish a foundational discourse between public health and local politics and generate theories of a local politics of public health.

Sullivan and Strach examine the political development of sanitation workers seeking power in public health agencies in the late nineteenth century, and the implications for public health and inequality. Using tools of American Political Development, Sullivan and Strach examine the inception of local public health through the sanitary movement of the nineteenth century. They find that while local political dynamics of both agency-professionalization and rent-seeking led to the bifurcation of these two fields in the early twentieth century, local public health departments would not have succeeded without the foundational contributions of sanitation. Strach and Sullivan furthermore establish a critical relationship between ideas about what constitutes public health, and for whom, and the development of local public health governance structures. The authors show us how the local political economy incentivized the professionalization of sanitation away from public health to promote business interests (regular cleaning and maintenance vs. quarantine measures), yet still providing an essential, collective public health service. Their research lays the groundwork for our understanding of why public health governance of different problems may function differently, regarding accountability, transparency, and capacity, through indirect or direct structures, and how conceptions of public health problems influence evolving governance arrangements or who is responsible for the provision of different public health services.

De Paula Moreira and colleagues investigate drivers of local media declarations of racism as a public health crisis in their communities, and the impact of public health declarations on local TV news coverage of racism. Public health declarations theoretically should serve important agenda-setting functions in local politics, by increasing salience or mobilization around public health problems—in this case, salience of highly marginalized problems for oppressed communities—yet whether or not such increased attention is seen is an open empirical question. While some new research has investigated the predictors of such declarations (Farris, Holman and Sullivan 2022), no research to date has considered the outcomes of public health declarations beyond individual case studies. De Paula Moreira and colleagues tackle this question with innovative primary data of public health declarations of racism in cities across the United States in 2020, paired with local television media news coverage as a measure of salience pre and post declaration. What the authors find sets the stage for future work: declarations of racism as a public health crisis were associated with more local TV news coverage of racism, while local media markets with a higher percentage of votes for Trump in 2016 were less likely to make declarations. As local media markets are an essential source of public health information (Gollust 2019), this research builds a foundation for our understanding of how conceptions of local public health,—for whom—can change over time based on democratic representation of public health problems in hyperlocal contexts.

Kelly and Kuo investigate the COVID-19 policy response at the county-level in California. The authors build on our limited knowledge of the functioning of LHDs, by seeking to explain why county public health departments were able to effectively implement COVID-19 policies for surveillance, prevention, and response, or not. They examine the conditional role of both formal and informal measures of public health capacity, and the influence of local elected political actors on the autonomy of public health bureaucrats to successfully carry out their duties and leverage their expertise, or not. This contemporary evaluation of northern California public health departments, in one of the most well-resourced states, sets an important precedent for future research into constraints on public health bureaucratic autonomy and capacity as national efforts by far-right actors seek to undermine key public health powers as part of broader anti-democratic efforts to demobilize the administrative state (Gadarian, Goodman and Pepinsky 2022; Singer et al. 2021). Yet, Kelly and Kuo find that indirect capacity, through professional networks and relationships, was often key to overcoming political opposition to life-saving public health programs that reduced COVID-19 case-fatality rates and improved health equity. Here, the authors build out the groundwork for our understanding of the horizontal relationships and political dynamics across direct and indirect domains of local public health, and their influence on local public health policy and outcomes.

Jarman and colleagues evaluate the continuum of public health governance across direct and indirect structures, and why such varied governance mechanisms may arise for public health problems: here, in the case of mosquito borne diseases in Florida. The authors find that governance for mosquito borne diseases was transitioned away from LHDs to local “mosquito control districts” precipitated by adverse public health outcomes and economic interests related to tourism. Today, mosquito control special districts are far better resourced in their ability to address mosquito borne diseases, with higher levels of expertise compared to LHDs. Yet, the authors find an embedded health equity challenge pertaining to the unique geographic relationship of mosquito control districts: as most special districts do not cover the whole municipality, jurisdictions served by a special district and not served by a concurrent LHD may receive insufficient or no mosquito control. This work bridges the questions of how horizontal relationships across direct and indirect public health domains may change overtime in the context of shifting vertical capacity, alongside the public health and political consequences of hyperlocal fragmentation and spatial concentration of public health goods along lines of inequality.

Collectively, these investigations offer insight into the relationship between local public health and democracy, as perceptions and structures of what public health is and for whom change over time. The studies in this symposium bring together two key features of a local politics of public health that should inform future research: the democratic dynamics of structures and policies that affect public health—both directly through Local Public Health Departments and indirectly through agencies not conceptualized as “public health actors”—and local jurisdictions’ ideas and choices regarding conceptions of public health. As public health problems and policies necessarily affect all citizens, the ways in which public health is governed; the power dynamics of this governance; and the feedbacks on ideas about perceptions of public health and the distribution of protective public health resources for some or for all; provide critical insights into not only the functioning of local public health, but also the functioning of local politics and democracy as buffers against oppression and inequality from which public health outcomes are intrinsically tied (Willison et al. 2022).