Local Public Health System Capacity and Its Relationship to COVID‐19 Mortality Patterns across the U.S

RESEARCH OBJECTIVE: As of January 5, 2020, the United States confirmed over 20 million cases of COVID‐19 resulting in at least 353,730 deaths. The public health response to COVID‐19 in the U.S. is trailing many countries and the bulk of the response burden is left to state and local public health systems. Studies comparing public health systems across the U.S. reveal gaps in the capacity and capabilities of public health systems at the state and local level. These gaps can lead to further disparities in public health access, policy enactment, emergency preparedness and preventable outcomes. Our study explores the potential associations between local public health system capacity and COVID‐19 death rates. STUDY DESIGN: Public health system capacity was assessed using a public health system composite measure developed from the National Longitudinal Survey of Public Health Systems (NALSYS). This measure combines information about the extent to which a set of 20 guideline‐recommended public health activities are implemented in the community (i.e., conducting needs assessments for the community's health status, investigating adverse health events, etc.) and information about the network of community organizations that contribute to implementing these activities. Combining this information into a composite measure resulted in three distinct classifications of local public health system capacity: Comprehensive, Conventional and Limited. Comprehensive systems deliver the most public health activities and have the largest network of community partners, while limited systems deliver the fewest public health activities and have the smallest network of community partners. Two‐part generalized linear models (GLM) were used to estimate the relationship between this system composite measure and COVID‐19 death rates while controlling for a range of population and community characteristics associated with COVID‐19 risks, distinguishing counties with and without at least one COVID‐19 death. Falsification tests and several model‐specification checks where performed to further verify the association between the system composite measure and COVID‐19 death rates. POPULATION STUDIED: The 2018 wave of the NALSYS includes a stratified national sample of 725 local governmental public health agencies. PRINCIPAL FINDINGS: Using mortality data between April and July 2020, counties served by comprehensive public health systems had 11.9 fewer COVID‐19 deaths per 100,000 residents than counties with conventional systems (z‐statistic = 3.13; p‐value = 0.002), and 9.94 fewer COVID‐19 deaths per 100,000 residents than counties with limited systems (z‐statistic = 3.69; p‐value <0.001) after controlling for other model covariates. These results remained consistent and significant when mortality data were included from later in the pandemic through January 2021. CONCLUSIONS: Communities with stronger local public health systems, as measured by scope of activity and network density, experienced significantly fewer deaths attributable to COVID‐19. IMPLICATIONS FOR POLICY OR PRACTICE: Efforts to contain the adverse health consequences associated with COVID‐19 and future public health threats should include initiatives to strengthen local public health system capacity, such as through increased funding, training and network coordination. PRIMARY FUNDING SOURCE: The Robert Wood Johnson Foundation.