In 2014-2015, the deaths of black civilians by police officers in many of our nation's communities, including Ferguson, Missouri, and Baltimore, Maryland, sparked national discourse and demonstrations regarding law enforcement's use of force, as well as race relations. Although these high-profile police incidents were catalysts for the unrest that followed, the root causes of this unrest are multifaceted, go back decades, and are grounded in the social determinants of health, including unsafe neighborhoods, unemployment, inadequate schools, and lack of access to nutritious foods and health care.1 Thus, these police incidents should not be viewed solely as a law enforcement concern, but rather a call to action for the United States to address the underlying social inequities that impact individual and community health. This call is particularly poignant for the field of public health, which emphasizes collective action to ensure conditions-including economic, social, and environmental factors-that are necessary for good health.2

These police incidents have shined a light on the dire consequences of and urgency to address the inadequate social determinants in many of our nation's communities. In addition, these incidents offer opportunities to assess and pose plans for remediation of other underlying issues, such as systemic inequitable practices and entrenched economic and political structures. One such issue, underscored in the Ferguson, Missouri, incident, is local governance structure, size, and function.

A municipality within St Louis County, Ferguson, population 21 000,3 maintains a municipal police force, city manager, town council, and court.4 Most of the 89 St Louis County municipalities maintain similar government structures.5 With small population bases, financially sustaining these entities presents challenges. According to a Missouri municipal government leader, "There are just too many towns, too many municipal governments, too many municipal employees, and not enough revenue to support them."5 Revenue generation and sustainability often trump departmental missions, such as public health and safety, as underscored by the US Department of Justice's finding that "city officials have consistently set maximizing revenue as the priority for Ferguson law enforcement activity which had a profound impact on the department's approach to law enforcement."6

There have been attempts to consolidate St Louis County municipal agencies or eliminate them and have county agencies provide services. For this consolidation to occur, municipalities would need to merge or dissolve their local councils, forcing individuals in local office to give up their power.5 Not surprisingly, these consolidation attempts have not succeeded.7

Similar to St Louis County's municipal entities, many US local health departments (LHDs) serve jurisdictions with small populations. The efficacy of such LHDs has been questioned, as well as the impact of structural changes or elimination of these LHDs on their communities.8 Given ongoing public health threats and increasing expectations for government accountability, these questions about governmental efficacy are imperative.

The National Association of County & City Health Officials reported 2531 US LHDs in 2013.9 Of these, 61% (1544) served populations under 50 000 (small LHDs) and provided public health services to 10% of the US population. Conversely, 5% (137) of LHDs served populations of more than 500 000 and provided services to 49% of the population.9 The number of LHDs varies, with 26 states reporting fewer than 50 LHDs, 18 reporting between 50 and 100 LHDs, and 5 reporting more than 100 LHDs.9

Local governmental entities serving populations under 50 000-including law enforcement and public health-likely reflect historical, cultural, economic, and geographic contexts and a community's identity and ability to customize operations to meet local needs.10 Consolidation options for public health are often debated,11 as research has found that small LHDs have less capacity to provide essential public health services than larger LHDs.6,7,12,13 Moreover, small LHDs provide fewer services at a higher mean per capita expenditure than larger LHDs.7

How can an LHD ensure adequate local public health protections? This question, contemplated by the Institute of Medicine's 1988 Future of Public Health2 report, continues to be debated. In 1994, the Ten Essential Public Health Services identified public health protections to be provided to all local US jurisdictions.14 In 2005, an operational definition for a functional LHD provided a set of LHD standards15 that then formed the basis for a voluntary LHD accreditation program initiated in 2011.16 The aim of the accreditation effort is to protect health by enhancing health department quality and performance across the nation.16 In 2013, a minimum package of LHD public health capacities and programs was developed.17

In tandem with defining LHD roles and responsibilities, the Ten Essential Public Health Services provided a framework to evaluate LHD performance.18,19 The National Public Health Performance Standards were developed to assess LHD capacity and performance within a larger public health system, to ensure adequate response to day-to-day public health concerns and emergencies.20

Despite these initiatives to ensure adequate public health protections for local communities, in past decades, attempts to alter LHD structures have generally been unfruitful.7,21,22 This is not surprising, as local leaders are often reluctant to "give up" local governmental entities.8 However, in the aftermath of the 2007-2009 recession,23 the nation's LHDs declined from 2794 (2008) to 2564 and 2531 in 2010 and 2013, respectively.9 This reduction was in small LHDs, declining from 64% of all LHDs in 2008 to 62% and 61% in 2010 and 2013, respectively. Conversely, during this period, LHDs serving jurisdictions from 50 000 to 499 999 increased from 31% (2008) to 32% and 34% in 2010 and 2013, respectively, whereas large LHDs (>500 000) remained at 5%.9 Hence, LHD reconfigurations can occur, particularly in times of declining resources. However, given historical difficulties in changing governmental structures and the nation's improved economy, such reductions are unlikely to continue without considerable effort and advocacy.8

At its core, a LHD needs to have the resources and capacity to provide adequate public health protections to the community it serves. If unable to do so, the efficacy of such LHDs should be questioned.

There is no one-size-fits-all local governmental structure; it depends on communities' circumstances, needs, and composition. In this era of ongoing public health challenges, persistent social and economic inequities, limited resources, and increasing demands for government accountability, it is critical to revisit such questions not only in the aftermath of high-profile incidents such as those in Ferguson and Baltimore, but also on an ongoing basis. Through this process, recommendations for change can be considered and posed to ensure adequate public health protection of all local communities.

REFERENCES