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Public Health and America’s ‘Forgotten Governments’

Counties and their public health officials have been on the front lines of the COVID pandemic, struggling amid white-hot politics that has weakened the nation’s response. Can we do better when the next pandemic strikes?

Cook County converted a former Target store in Matteson, Ill., into a mass vaccination site during the pandemic.
(Mike Nolan / Daily Southtown/TNS)
One of the most important but least-explored lessons of the COVID-19 pandemic is the central role that counties play in public health. They are the operational center of our war against the virus, but that role has often been hidden behind the veil of what scholars have called America’s “forgotten governments.”

It’s easy to think of well-known governors, from Maryland’s Larry Hogan to Florida’s Ron DeSantis. And mayors get tons of publicity beyond the cities they lead, like Eric Garcetti in Los Angeles and Eric Adams in New York City. It’s hard, though, for even careful watchers of American government and politics to suggest the names of county officials who have any kind of profile beyond their jurisdiction’s borders.

Despite the outsized public face of feds like Anthony Fauci, the policy function of the Centers for Disease Control and Prevention, and the regulatory power of the Food and Drug Administration, public health has always primarily been a state function. The states delegate the frontline role to the counties, but that job has gotten little attention.

Part of the reason for that is that counties, by any measure, are peculiar animals. As of 2017 there were 3,031 of them, according to the most recent count by the Census Bureau. Texas is the champ with 254 counties. Delaware and Hawaii each have three. Georgia, with about one-tenth the population of California, has almost three times as many counties. Connecticut is something of an outlier: Since 1960 its counties have existed only as geographical regions, with no duties or functions.

New York is one city that encompasses five counties, matching its five boroughs. In the city of Los Angeles, mayors have complained about how weak their power is, while Los Angeles County is far larger and encompasses more than twice as many people: Each of its five county supervisors represents more people than the U.S. senators of a dozen states.

And then there’s Philadelphia, where the city and county boundaries are the same and the county has no government of its own. In April, when the city brought back the COVID-19 mask mandate and then quickly reversed itself, it was Philadelphia acting as a county. And when New York City haggled over its own mask mandate, it was the city acting on behalf of all five counties.

Add one more ingredient to this bizarre mélange. California set a statewide mask mandate, but in practice it varied across the state — by county. In Orange County, always stubbornly conservative, there was some question about whether county officials ever enforced it.

It’s not surprising, therefore, to discover that county boards and commissions have a partisan tilt and that this tilt has affected policy. In 1990, these governing bodies were about evenly balanced between Republicans and Democrats, but since then Republicans have gained an edge, moving the boards toward a more conservative stance particularly when it comes to taxation and spending. On the other hand, as Justin de Benedictis-Kessner of Boston University and Christopher Warshaw of George Washington University found, electing a Democrat to a county board not only tilts it more liberal but also boosts an average county’s spending by 5 percent.

Caught in the Middle

These cross-pressures collided on the front lines of public health during the pandemic. Combine the important but often invisible role of public health in the United States, look at the counties where the frontline public health work happens, add the conservative-leaning (and often anti-masking) decision-making by many county boards, and stir in the tremendous stress of navigating through the pandemic.

The result: In a CDC survey published last summer, more than half of all public health workers reported symptoms of mental health conditions including depression, anxiety and suicidal thoughts. One in eight local public health workers had received threats during the pandemic. One-fourth felt bullied or harassed.

And in the first year and a half of the pandemic, half of the states reined in the power of public health departments. One in five Americans lost the leader of their local public health agency, as this Kaiser Health News map from last September illustrates:
Kaiser map
The counties and their public health officials have been the foundation of the nation’s response to COVID-19. They were the prime local data-gatherers and the principal feeders of the information to the CDC. After the initial frantic scramble to set up vaccination clinics, the counties became the local coordinators for the shots, from giant Cook County encompassing Chicago to tiny Garfield County in Colorado.

When local politics got white-hot and pressures grew to avoid damaging local economies, however, elected officials pushed public health experts to the sidelines. That, in turn, weakened the nation’s response to COVID-19. “It’s been a bit of an uncoordinated disaster,” explained Lori Tremmel Freeman, the CEO of the National Association of County and City Health Officials. It was hard for public health officials to enforce the position many governors had staked out, which, she said, “basically villainizes” the local officials. And because many of the local public health experts had been frozen out of the policy discussions, she explained, “it’s really hard to be a partner in that work when you haven’t been allowed into the group that informed the decision.”

Century-Old Lessons

We know, of course, that future pandemics are sure to come our way. And from a scientific standpoint at least, we know what should be done. As David M. Morens and Jeffrey K. Taubenberger wrote in the American Journal of Public Health, “We appear to stand at the threshold of discoveries that will one day save millions of lives if, or rather when, another highly fatal influenza pandemic emerges.” In fact, they observed, “we have substantial knowledge about pandemic risk management, including standard public health measures to protect individuals, and more effective cooperation between medicine and public health.”

Morens and Taubenberger published that article in 2018, before COVID-19 started its awful campaign, and they based their analysis on lessons learned from the “mother of all pandemics” a century before. When the next pandemic did emerge, we began the grim march that so far has cost a million lives just in the United States, largely because we struggled to follow the lessons they outlined.

The U.S., in fact, has suffered far more from COVID-19 than many other countries with stronger national strategies, like Japan and South Korea, as well as three countries with federal systems like the American one: Australia, Canada and Germany.

When the next pandemic strikes, we know what to do, both from the lessons of the 1918 outbreak and from the experience of other countries with COVID-19. For America, the lessons begin with rediscovering the bedrock role of counties in public health — and providing them with air cover when the tough decisions needed to tamp down pandemics create the fierce blowback that has eroded our frontline defenses over the last two years. Given what’s happened in the COVID-19 pandemic, it’s hard to be optimistic. But America isn’t incapable of learning from its mistakes. We don’t, however, need to make learning so hard.

Governing's opinion columns reflect the views of their authors and not necessarily those of Governing's editors or management.
Donald F. Kettl is professor emeritus and former dean of the University of Maryland School of Public Policy. He is the co-author with William D. Eggers of Bridgebuilders: How Government Can Transcend Boundaries to Solve Big Problems.
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