The Local Politics of Public Health
In this two-part miniseries, UAR Remixed speaks with several authors from the journal’s recent symposium, “The Intrinsic Relationship between Local Politics and Public Health.” We speak with the authors about their research, which covers a wide breadth of topics and ideas at the intersection of public health and politics in local contexts. In Part 1, we meet the authors and learn more about the big questions and pressing issues that prompted them to do this research. In Part 2, we’ll be thinking about the inherently political nature of public health policy, and how our present political climate is affecting public health research and institutions at the local level.
Guests
Nátalia de Paula Moreira, PhD. Postdoctoral Researcher, Wesleyan University.
Sarah Gollust, PhD. Professor, Health Policy and Management, University of Minnesota.
Andrew Kelley, PhD. Assistant Professor of Public Health, Cal State East Bay.
Didi Kuo, PhD. Center Fellow, Freeman Spogli Institute for International Studies, Stanford University.
Holly Jarman, PhD. Associate Professor, Health Management and Policy and Global Public Health, University of Michigan.
Patricia Strach, PhD. Professor, Political Science, University at Albany.
Kathleen Sullivan, PhD. Professor, Political Science, Ohio University.
Charley Willison, PhD. Assistant Professor of Public Health at Cornell University.
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Charley Willison
But I was always really curious about this omission of local politics and local policies in general, again, especially because so much of what we think of as public health is carried out in these decisions that are impacting public health and populations are happening at the local level.
Holly Jarman
It's extremely important to understand, for me, how public services are delivered locally when it comes to things like mosquito control. But also, I just have a fascination for odd policy solutions, for odd institutions, and I am a bit of a nerd about these sorts of things.
Patricia Strach
So we used to do something on the individual basis and now we do something collectively by government and in terms of thinking about ideas as the as the kind of the emulsifier, right? This can bring people together, so it can bring people in, and how these ideas can be not so rigid, but they can be malleable enough to last for a very long time.
Sarah Gollust
After 2020, with the murder of George Floyd in Minneapolis, where I live and work, along with the sort of proliferation and dissemination of evidence about the differences in health outcomes related to COVID, the movement from kind of a research understanding became a much bigger policy or political understanding of that connection between racism as a public health crisis.
Andrew Kelly
It was about having the ability to implement policies and not being captured by societal interest, but you still have some level of connectivity to those societal interests, so you can understand what is needed. You can rely on that partnership to help implement policies as well as to develop those policies.
Emily Holloway
The politics of public health have emerged as a fundamental social issue in the US over the last five years – this shouldn’t come as any surprise, especially in the wake of COVID, a rapidly growing vaccine skepticism, and the persistent gap of health outcomes for marginalized communities. But these are often understood at the national level – think about the CDC or Medicare and Medicaid coverage. What role does the local play in all of this? How do cities – inherently local geographic units – shape the development, the implementation, and the success and failure of public health policy?
I’m Emily Holloway, and you’re listening to UAR Remixed, a podcast companion for the journal Urban Affairs Review. In this miniseries, I’ll be speaking with the authors of our journal’s recent symposium, “The Intrinsic Relationship between Local Politics and Public Health,” guest edited by Dr. Charley Willison, an assistant professor of public health at Cornell University. In this two-part series, we’ll go behind the scenes of each author’s contributions to this symposium to better understand this intrinsic relationship between the local and public health policy.
Charley Willison
I'm Charley Willison. I'm an assistant professor of public health at Cornell University. I'm a political scientist, and my research focuses on the local politics of public health. I think a lot about political decision-making and explaining public health policy outcomes, specifically as they pertain to very at risk or marginalized populations, and most of my work focuses substantively on homelessness and disaster policy responses.
Emily Holloway
Charley, thanks so much for organizing this timely and urgent collection of papers. Can you share how this initially came together?
Charley Willison
I did a joint PhD in political science and in health policy, and something that I noticed was, while so much of public health and health policy, but more so public health specifically, as opposed to healthcare services, is really designed and delivered at the local level. However, most of health policy research – we can also think of this as health services research – really focuses on federated relationships, specifically states and the federal government. Now, this is really important. We have to look at federalism and the role of states and the federal government in order to be able to understand healthcare policy. But I was always really curious about this omission of local politics and local policies in general, again, especially because so much of what we think of as public health is carried out in these decisions that are impacting public health and populations are happening at the local level. And so when I started to do work on homelessness as well as on other issues that are really focusing on extremely high risk or highly marginalized and oppressed communities, I found a gap in research where the discipline of health, politics, and policy really tends to coalesce around, again these federated relationships in the same way that health services and health policy research does, and by a different vein or counterfactual, urban politics research, urban and local politics, which I learned so much from, they're really talking about all of these different dynamic issues, from democracy to political economy, that are shaping different goods and services and public resources that we know affect public health. But they're not talking about public health.
So I've been aware of this gap for a really long time, and I would say this is probably a long time coming that I have wanted to pursue this as a broader research agenda and to really have these conversations across these two communities within political science, health politics, and urban and local politics, but also to make this known to public health, and I'll end there in saying that despite these disciplinary divides in political science talking across each other around public health policies, we also see that public health generally really doesn't – as a as a field or as a discipline – doesn't really think very much about politics, and this is ironic because when we look at studies of public health, public health knows that all of these different higher level factors, things like the neighborhood that you live in, the education and income levels that you attain, have the greatest effect on your health outcomes across the life course much more so than your ability to access healthcare, but public health treats these other categories as units of analysis or independent variables, and doesn't really think about these upstream causes of, for example, why might different neighborhoods that have different levels of public goods? Public health really has not thought much about that, so that's just another piece of the puzzle as to why public health can learn so much from political science in explaining these really deep, persistent disparities in public health outcomes.
Emily Holloway
Different articles in the symposium looked at these disparities in different ways. I also spoke with Nátalia de Paula Moreira and Sarah Gollust, who, with co-authors Steven Moore, Breeze Floyd, and Erika Franklin Fowler, wrote the article, “Racism as a Public Health Crisis: How Declarations Shape Local TV News Attention to Racism,” to analyze media coverage of local-level declarations of racism in relation to issues of health equity.
Sarah Gollust
My name is Sarah Gollust. I'm a professor in the division of health policy and management at the University of Minnesota School of Public Health, and my research interests concern the intersection of media, communication, and public opinion about health policy.
Nátalia de Paula Moreira
Hi, I am Nátalia de Paula Moreira, I am a member of the COMM team and I am also a professor and instructor at the University of Sao Paulo Summer School in methods and political science, and my areas of interest are public opinion, political methodology.
Emily Holloway
Sarah, Nátalia, thanks so much for joining us. How did this work come together?
Sarah Gollust
So, we are all members of a research team called the Collaborative on Media and Messaging for Health and Social Policy, which is called COMM for short, because it's quite a mouthful. We're an interdisciplinary group of researchers who study the relationship between media and public health policy with a central focus on health and racial equity and the overall research team spans affiliations with three institutions: the University of Minnesota, Wesleyan University and Cornell University.
We span disciplines, so psychologists, communication, journalism. I'm a public health scholar, focusing on health policy, but we really span the gamut of researchers. But we're connected, because we're all really interested in understanding the dynamics around media and policy, and particularly policy related to health equity. So, understanding this specific issue of this paper, which is around media coverage of declarations of racism as a public health crisis, is really squarely within the scope of our team. So, in starting this paper, we were really interested in trying to understand how and to what extent the news media paid attention to declarations of racism as a public health crisis.
These really proliferated in 2020 and in the years following it, and as a research team, our central goal or sort of the puzzle that fascinates us as a whole team, is understanding the factors that shape the way the public is exposed to and conceives of and understands issues related to health and racial equity, and so that is why I think our team gravitated toward this question as a puzzle of interest.
Emily Holloway
And so how did you go about studying this puzzle?
Nátalia de Paula Moreira
So, we had three central questions that guided our study. So, the first one was where and when were declarations enacted? The second one, what community level factors predicted whether declaration occurred, and finally the third question was did the declarations increase media attention to racism? So having those questions in mind, we started first by collecting data on declarations of racism as a public health crisis, and we compiled a database of 250 declarations from January 2020 to March 2023, based on records from the American Public Health Association, and these declarations came from cities, counties, states, and public health departments, among others.
Once we have those declarations in hand, we then collect started to collect data on local TV news coverage, so we use close captioning transcripts from local TV news broadcasts collected by the media project. And we searched those transcripts declarations of racism to measure media attention, so our measure of media attention is the number of mentions.
So, with those data in hand, we also wanted to collect the contextual variables and data on contextual variables. So, for that, we collected data on the percentage of black residents in the in the community, the percentage of insured population, the percentage of votes for Donald Trump in 2016 election, percentage of infant mortality as a proxy for health inequalities, among other variables.
So, once we had this data set, this big data set with data from this all different sources, we then analyze the data at the media level market which is which reflects the geography of the local TV audiences, and this allowed us to connect declarations and the media content within a coherent geographic unit. And for analyzing the data we have run a few statistical models. So, we first estimated logistic regression models, which is a statistical approach to see if there is a correlation between characteristics of the community, for instance racial composition, insurance coverage, voting patterns, and the likelihood of declaration being enacted and the city, county, and state level.
And finally, we also estimated time series models to assess whether there was a relationship between the passage of a declaration and mentions of racism on local TV news, both in the short term and the longer term over the months following the declarations passage.
Emily Holloway
There’s a lot of research about the partisan divides of media, in print and in television, social media. But local media, especially TV news, seems to be a bit more resilient, maybe a bit more trustworthy.
Sarah Gollust
I think as academics, we often overlook the role of local TV news, thinking like, oh, not that many people maybe watch it or it's sort of we should attend to what the New York Times is saying or what the Washington Post is saying. But in fact, many, many Americans watch their local TV news. It's part of local communities. It also has more bipartisan viewership, which I think is really important when we think of today's climate, and then from a from a local politics perspective, it's really important to have and support a healthy local news ecosystem because the local news, if provided the opportunity and sufficient resources, can track local policymaking like declarations of racism as a public health crisis and be more accountable to the actions of local officials.
And so, I think just really reminding people about the ongoing importance of local news, including local TV news, is really critical. And as we are so attentive to the fights that are happening at the federal level, I think we just shouldn't lose sight about maintaining and bolstering the role of local news outlets to cover what's happening at the local level.
Holly Jarman
So, me and my colleagues have been talking for some time about public health capacity, and so much public health work happens at the local level. It's extremely important to understand, for me, how public services are delivered locally when it comes to things like mosquito control. But also, I just have a fascination for odd policy solutions, for odd institutions, and I am a bit of a nerd about these sorts of things.
Emily Holloway
The local – whether we’re looking at a city, a municipality, even a county – is really one of the major structuring geographies of these papers. Public policy, especially health policy, plays out on this terrain in very different ways than it does at the national or even state level. Holly Jarman, who you just heard, along with co-authors Phillip M. Singer, Iris Holmes, Jessica Hsu, Chloe Harper, Naquia Unwala, and Charley E. Willison, look at another local typology: the special district. Their article, “Draining the Swamp: The Local Governance of Mosquito Borne Diseases in Florida,” examines public health policy through the governance of special districts – and specifically, those created to manage mosquito control.
Holly Jarman
My name is Holly Jarman. I'm an associate professor of health management and policy and global public health at the University of Michigan.
The US has thousands of special districts. They're so numerous and sometimes ephemeral or short lived, that we actually have to count them. And some of these special districts actually deliver public health services. So, we found out that some states in the United States have special districts dedicated to public health services like mosquito control and to me, that was just so interesting.
Why on Earth do we have these special districts which are – partly they're public institutions, they have democratically elected commissioners, they collect taxes, and they provide these important public services, but they're also largely ignored. So, in practice they cater to only a small slice of the local population. They can become captured by small groups of private interests and so I wanted to know, do these special districts work for delivering public services? What do they mean for democracy? What do they mean for public health?
Emily Holloway
So, Holly, what are special districts? How do they work – or do they work at all? Do you think they’re effective?
Holly Jarman
So special districts are independent local governments that only focus on one thing most of the time. So, in our case that was mosquito control.
We have had a lot of special interests over time, and they've actually increased in number in the US over the years, and we have to survey how many of them are there and what are they doing, because there's not a stable population of governments. So they're an unusual form of government in that they're only focusing on one thing and trying to deliver that to an area which might be the same size as a local jurisdiction like a county, but might actually be part of that area, and so when it came to delivering a service like mosquito control, we were really interested in whether that actually made a difference, whether we have a special district or whether we have a jurisdiction like a county that does all these other issues. It's a whole government that thinks about local politics in a connected way, does it make a difference to have this special district focusing on one thing?
There's quite a lot of research on special districts in the US, and a lot of this research focuses on a couple of different things. People are asking questions about whether special districts are efficient because quite often they lie on top of other governments. Are they wasteful because they quite often raise their own taxes?
You might receive your tax bill in some areas, and there's lots of different line items for the different special districts that are able to raise their own taxes. And I think that can be quite confusing for someone like me who's just trying to understand what their money is paying for in terms of public services.
So, we think about whether special districts are wasteful. We think about whether they're accountable, whether they're democratic, because they're often not very visible, but it could be confusing to someone who says, well, what is this district? What does it do and how is it distinct from the other local governments that are active in my area?
We also think about whether special districts do a good job of matching the services they provide to where the need is. So as a public health researcher, I care quite a lot about whether special districts are equitable, whether they are effective, are they actually delivering what the public would want, or are they serving a smaller group of local interests that are maybe the most mobilized and sometimes the most wealthy?
Emily Holloway
I don’t know how intuitive the connection between mosquito control and public health is for many people – when you stop to consider it, certainly it is. But it probably doesn’t associate automatically with the average person when they think about public health, certainly not special districts – I don’t know if many people think about special districts at all, though.
Holly Jarman
It's really important to study mosquito control because of the ways that mosquitoes are a vector for really important diseases that we're worried about in public health. So, you might have heard of Zika, West Nile virus, or malaria. These are not the only diseases that are spread by mosquitoes, but they're really significant in terms of affecting our health and so fortunately, we have really effective means of controlling those populations of insects that spread disease, and that's actually, historically in some parts of America, those strategies for mosquito control have been really effective.
At the moment we're in a situation where provision of public health services is being challenged across the board. We're also in a situation where funding, even where public health services do exist and programs exist and jurisdictions that are like our special districts, that provide these services exist.
They tend to be underfunded, so one of the reasons we were interested in taking a look at special districts is the question of whether or not they actually have a better ability to leverage money and provide dedicated services. Are they doing that better than some of these other local jurisdictions?
Because in our case of Florida, the state level funding for mosquito control has decreased quite significantly over time. And so, whether or not you live in a place where there's good public money and good resources and expert staffing for mosquito control makes a real difference in the health of your community. So, we wanted to know: Does it matter that you live somewhere with a special district providing those services, or does it matter that you live somewhere where a county is providing them?
And overall, we find that the special districts are providing these services at a higher level to the extent that we can measure. So it does tend to matter, we think, that there's a dedicated government for mosquito control with a defined mission and the ability to raise its own money, but at the same time, those special districts have boundaries that don't necessarily cover the whole community, so they reinforce this sense that public health services in these cases are locally bounded. They're not usually available to those outside of a specific geographic area.
Emily Holloway
Mosquito control isn’t the only public health capacity the authors studied in this symposium. What about...garbage? As Mayor Fiorella La Guardia once infamously said, “there is no Democratic or Republican way to pick up garbage.” Trash collection – a sanitation service – is an absolutely essential public service in cities. It’s one that you always notice when it’s late, or stops.
Emily Holloway
But essentially, it’s a public health service. Sanitation services span a wide range of responsibilities, from sewage treatment to drinking water to clean streets and trash and recycling. But they’re not a given, and, despite La Guardia’s claim, they are often at the center of political struggles for power. I spoke with the authors of “Ideas, Municipal Sanitation, and the Transformation of Public Health,” to learn more.
Kathleen Sullivan
I'm Kathleen Sullivan. I'm a professor of political science at Ohio University, and my fields are American political development and public law.
Patricia Strach
I’m Patricia Strach. I'm a professor of political science and public administration and policy at the University at Albany, State University of New York, and my areas of interest are public policy and mass politics.
Emily Holloway
Kathleen and Patricia, thanks so much for joining us. Why garbage?
Patricia Strach
Well, Kathleen and I have been working together for about 20 years, and we were very interested in understanding how government solves public problems. And we decided to look at trash collection because it's such an interesting case. So, at the same time, in cities across the country, the same problem was arising.
And so how did governments solve that problem? So that's how we came to understand and to think about garbage collection and public health, kind of came about it in a round way, because we wanted to know how government solve public problems, and then in the course we wrote a book, The Politics of Trash, and then some that we were interested in this idea of sanitation. There's all kinds of ways to solve public problems. The cities across the country were all kind of adopting the same idea behind their measures.
Kathleen Sullivan
And in studying the development of municipal garbage collection in the 1890s, we kept bumping into sanitarians of that time period because they had professionally organized and were trained at that time. They were collecting these wide scale studies of garbage collection in cities across the country, and so we had our eye on them and we did rely on them for data. But even after we wrote the book, we continued to think about the sanitarians of that time period. And so this project was a chance to really put that at the forefront.
One thing that struck us is that we had studied the development of municipal garbage collection in the 1890s, and sanitarians had really been at the forefront of pushing for municipal garbage collection. And so, their ideas rested on the notion that household garbage was dirty. So if you had rotting food waste or animal carcasses that could run into the waterways, it a presented a public health hazard, and so the way they responded to that was to send carts around to pick up residents’ waste and then just get rid of it, move it outside of the city center. And one thing we were struck by, is that is still how garbage collection is done in the United States for the most part. And in some cities, garbage collection departments are still called departments of sanitation, so it has been an enduring idea, and that's what we wanted to keep an eye on, because of course, we have a lot of innovations in the 21st century. We have recycling and compost and zero waste. But why are we still calling it sanitation? And why are most cities still operating under the idea of sanitation?
Emily Holloway
So, your article is looking at this evolution through the framework of what political scientists call American Political Development, or APD. What does that mean, or what can APD show us about these historical changes?
Patricia Strach
So, we were really interested in understanding this idea of durable change, and one way of thinking about durable change is a change from these private practices to kind of a government provided service. So how did that particular change happen? And then within APD, we tend to think about these breaks from the past, these changes, these frictions, and we don't think much about the continuity that happens. And so we really thought about the – we took kind of one branch of APD and thought about the role of ideas, both in terms of, yes, creating that durable shift, right. So, we used to do something on an individual basis, and now we do something collectively by government and in terms of thinking about ideas as the kind of emulsifier, right? This can bring people together, so it can bring people in, and how these ideas can be not so rigid, but they can be malleable enough to last for a very long time. So, we used APD to kind of think about these durable shifts, not only as the break from the past, but as what allows continuity to happen.
Kathleen Sullivan
And what we found was that although there were varying interests who were interested in garbage collection at the time and could have been the runners of garbage collection, those interests ended up tapping into the idea of sanitation rather than competing with sanitarians.
Patricia Strach
So one of the things that we've always liked about studying garbage, even though people laugh at us sometimes because they think that that this is not what we think of when we think about health. But we take so much for granted, right? We just think like, oh, garbage, that's such a funny niche issue. But it is kind of the fundamental basis of public health.
And so, one thing that we find is through these garbage collection programs, it transforms not just health and municipalities, which it does by increasing the life expectancy and decreasing infant mortality. But for the United States as a whole, right? So, the health measures go up, because the problem in cities are so great, the rampant spread of disease. So, we take for granted a lot of these kind of public health measures, and we take for granted the political – that those are kind of nonpolitical. So one thing in looking at this these sanitarians with their 900 page books of data and it looks so what we would think so scientific, and it so seems so benign, it's very much political and it's very much about power by bringing some people into the folds, they're bringing the businessmen in with them, and they're bringing the engineers with them, and they're pushing out the scavengers and they're putting the cost on particular residents who live in the neighborhoods where these kind of facilities to remove trash are going to be located. So, a lot of what we think is just a really good thing, trash collection is a good thing. We don't even think about it. We take it for granted that cities are decent places to live. Now, all of this, we like to recover, and we tie it to the idea of sanitation that these sanitarians pushed.
Emily Holloway
So, we’ve talked to the authors about several different angles into public health at the local level – through service provision like trash collection, or special districts that manage mosquito control, and the role of the local media in disseminating information about long-standing disparities in public health outcomes to inform the public and help to shape public opinion.
Charley Willison
How do we get money to public health departments, or other types, even when we're thinking about social determinants of health, things like public schools, how do we get capacity for these different actors to do different things that requires allocation of resources, whether that's staffing or funding from higher levels of government?
Those are all political decisions, even if we think about, for example, where different public goods are located within a city, right? Does your city have or does your neighborhood within your city, have access to parks or safe sidewalks or public transportation, or mosquito control or trash collection. All of these different choices, they don't just exist for no reason, they don't exist in a vacuum, they don't happen haphazardly. These are all political choices that are made by different groups, and different groups have varying degrees of political power that make those outcomes more or less likely, depending on your positionality.
Emily Holloway
Different groups – not just elected officials, public health experts, or policy makers – but organizers, activists, advocates, residents deeply invested in and involved in their communities – all of these stakeholders play a key role. But what about implementation? How do you inform people about new initiatives behind vaccinations, masking, social distancing? The authors of “Building the Plane While Flying: Informal State Capacity, Policy Autonomy, and Public Health,” look at this gap in capacity and implementation across California during the COVID 19 pandemic.
Didi Kuo
I'm Didi Kuo, a center fellow at Stanford's Freeman Spogli Institute for International Studies. I work on comparative and American politics, particularly democracy, political parties, corruption, and apparently, health policy.
Andrew Kelly
I'm Andrew Kelly. I'm an associate professor in the Department of Public Health at California State University, East Bay. My primary focus is American public policy, particularly healthcare policy and public health policy, and interested in issues of policy innovation and state capacity and how states respond to new or emerging crises, particularly around health policy.
Emily Holloway
Didi and Andrew, how did you come together to collaborate on this? What drove the investigation, and why California?
Didi Kuo
Over the summer in 2020, Andrew and I had very similar personal experiences of being trapped at home with small children. So we really wanted to tackle this question of why some places seem to be doing better than others in terms of their COVID strategies, and particularly at the local level, because you had stuff happening nationally, stuff happening with the states, but in California at least, the county was really what mattered. And that seems to be true in a lot of other places. So, I was collecting data with a team of research assistants on county level attributes, and it turns out that Andrew was collecting data on.
Andrew Kelly
We’re both based in the Bay Area, which was such an early mover on COVID policy and really observationally, very ahead of most of the country, even other parts of California and the state of California itself. So, we were living in this really interesting case in the Bay Area, that was within California itself, which was also an early mover relative to other states. But seeing that happen around us in our communities, seeing that happen, play out in the paper, and just being, what's going on? And for me as Didi was saying, I got really interested in understanding what was driving decisions about reopening early on, right. Why were some counties reopening more quickly when the problem itself seemed fairly similar across all these different locations?
Then you can understand how to how do institutional differences lead to policy differences within this similar environment. So I think it was also being out here in the Bay Area too, and seeing a lot of this really high capacity really leading policy being developed by our county officials.
Emily Holloway
So, in your article, you’re looking at this problem, this gap, between public health capacity and policy implementation. And you do this by looking at the different stakeholders and actors in this dynamic, which are broadly divided into formal and informal capacities. Can you explain to our listeners what you mean by capacity, how you draw this distinction between informal and formal?
Didi Kuo
We drew a lot on the state capacity literature in comparative politics, which is fundamentally about a state's ability to formulate and implement policies. But we noticed that a lot of the literature, whether about state capacity or public health capacity, doesn't really distinguish between policy formulation and policy implementation, and a lot of times the empirical study of capacity can get a little tautological. Like you know it when you see it or you take policy implementation as a sign of capacity, so we wanted to disaggregate the concept and apply it to public health because it seemed as if many of the counties or all of them in California have the formal institutions necessary to formulate policy, and by formal institutions, we basically need resources, staffing, a bureaucratic apparatus, an agent, a health officer who has autonomy to develop decisions and usually has expertise as well, and then we wanted to separate that from policy implementation. So, once you've formulated a policy, if you do, how then do you implement it? And ultimately the paper came to be about why formal capacity only gets you so far in developing and implementing policy. What really matters are informal components of capacity that are critical to helping the state achieve its goals.
Andrew Kelly
I think along those lines, we were also starting to see this idea that was looking at these very formal measures that Didi mentioned in terms of, the number of scientists or how much lab space you had or how much your public health officer was getting paid or how big your staff was.
All these indicators of, okay, there seems to be expertise and ability there, but how does that get translated into policy? That difference between development and implementation became really important for us and something that we wanted to really drill down on. And that grew a little bit out of some of the work that someone named Martin Williams had done previously, where really, starting to say well, there's this like potential for capacity, like yes, these counties have an expert public health officer and they seem to have lab space, and they seem to have a lot of large budgets and they can develop policies. They have the potential to implement policy, and they have the potential to produce these good outcomes. But what sticks in the way? Are there things that stick in the way, whether politically, ideologically, institutionally? What determines whether a county can actually develop that and then turn that potential for policy capacity into something that's actually implemented and effective in producing policies that protect the general welfare and maintain public order.
Emily Holloway
So, it’s also about effectiveness – the public has to be educated, you have to reach them in some way, persuade them, build trust – not an easy task, especially during the early stages of COVID.
Didi Kuo
So when trying to implement different kinds of educational or disbursement of government resources or infrastructural type benefits, public goods, basically in general, to different populations, there are things that make bureaucrats more or less effective. So, the more that institutions are embedded into different groups or constituencies, the more likely they are to be able to implement policies and develop capacity. So drawing on work that has tried to apply this concept of embeddedness, sometimes it looks at how similar bureaucrats are to the populations that they are implementing policy within, but we started to think about variables such as community ties and the personal networks and relationships that bureaucrats have, and the extent to which you have formalized stakeholders into consultative or collaborative policy making, but into mechanisms that have them routinely interact with the state. Those are all ways that you buttress state capacity, but you don't observe it necessarily if all you're looking at is the institutions.
Andrew Kelly
It was about having the ability to implement policies and not being captured by societal interest, but you still have some level of connectivity to those societal interests, so you can understand what is needed. You can rely on that partnership to help implement policies as well as to develop those policies. And again, those aren't like formalized actors within the state, but it's partnerships between important sets of actors that are operating, state-based and non-state actors operating in the same policy realm.
Charley Willison
So what do you do if your local public health department has a bunch of money, has a lot of staff, but you are getting pushback politically from your Board of Supervisors, right? Saying, actually, we're going to take away your authority to be able to do quarantine or to be able to have mask mandates at schools.
All these different non-pharmaceutical interventions that are very effective, but they're not effective if you can't make them happen. And something that I learned a lot from, and I'm hopeful about, was that they find that local health departments through informal capacity, so these other measures, things like coordination, and their ability to work with local and regional partners in different ways, and especially their ability to work with more traditional political actors. So, elected leaders, bureaucrats and other agencies, that is something that helped them overcome some of these challenges and actually enact policy change and implement different policies even when they were facing intense pushback. And so that's something that I think the local health departments and other types of public health agencies can learn a lot from now is what do you do if you're losing capacity, and especially if you're losing formal capacity.
Emily Holloway
That was Charley Willison again, reflecting on Andrew and Didi’s article. In our next episode, we’ll be back with our guests to think through this symposium in the present – a very different present than the one these articles were written in last year. And we’ll be thinking through the political valences of public health more carefully.
Patricia Strach
Everything about public health is political.
Sarah Gollust
We're having this conversation in 2025. Where the world looks very different than it did in 2020 and lots of both good and bad ways, I think. And so, I think if we were to look at the study now, I'd be really keenly interested in understanding what has become of these declarations. Have communities sustained them? Have they repealed them?
Holly Jarman
So, I'm a political scientist, so my tendency is to think that everything is political. But I would say that public health is inherently political
Emily Holloway
You’ve been listening to UAR Remixed, a podcast by Urban Affairs Review. Special thanks to Drexel University and the editors at UAR. Music is by Blue Dot Sessions. This show was mixed and produced by Aidan McLaughlin and written and produced by me, Emily Holloway. You can find us on Bluesky at @urbanaffairsreview.bsky.social for updates on the journal and the show. Please rate, review, and subscribe on Apple, Spotify, or wherever you get your podcasts.
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