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Commonwealth:  A Journal of Political Science       Volume 14, Number 1      December 2008 
Special Policy Issue on Public Health             2008 PPSA/LORL, PA House of Reps.  ISSN 0890-2410 

 

 

 

Objecting to Public Health – Stories from Four 
Pennsylvania Counties 

 
Dennis Gallagher, MA, MPA, Drexel University 

School of Public Health 
Jennifer Kolker, MPH, Drexel University School of Public Health 

 
 

Stories from Four Counties 

This should be a very nice story to tell: most people – from the 
average citizen to the elected official – believe in the importance of 
protecting and improving the public’s health, and they also believe that 
where, how and when you do so really matters.  Yet it’s not true – not for 
many, and maybe most, Pennsylvanians. The message that Drexel 
University researchers often heard throughout three years of working 
with wonderfully committed organizations and individuals in four 
Pennsylvania counties is that – for very many people – attending to 
public health locally is at best unimportant and wasteful, and, at worst, 
threatening. 

One of the national goals for improving the health and quality of life 
of all Americans is to ensure that all public health agencies – including 
local ones – have the infrastructure to provide essential services 
effectively (U.S. Department of Health and Human Services, Healthy 
People 2010). Why? First, there are environmental threats: natural 
disasters (floods included) and man-made ones (bioterrorism especially) 
that would require direct, local, “hands-on” intervention; and many 
causes and sources of air, water, and ground contamination. Second, 
there are existing, and potentially catastrophic, threats of disease 
epidemics. 

Third, there are many behavioral risk factors, such as smoking, poor 
diet, physical inactivity, and excessive drinking, that are linked to the 
leading causes of death in the United States. Confronting these 
behavioral risk factors through health education and promotion, and 



84 OBJECTING TO PUBLIC HEALTH – STORIES FROM FOUR PENNSYLVANIA 
COUNTIES 

 
 

 

using preventive health measures like hypertension screening, can 
substantially reduce the rates of serious disease and death in the United 
States population (Chowdhury et al. 2007). Public awareness and 
knowledge of these risks, and concerted action to deal with them, does 
vary substantially by state and locality – often owing to the depth and 
quality of public health agency presence at the local level. 

The reasons why the public should favor more local public health 
presence in Pennsylvania are easy to enumerate. The math alone is 
simple: 67 counties, six countywide health departments, and four multi-
functional municipal ones in four other counties. As the readers of this 
Journal likely know well, the remaining 57 counties rely mostly on the 
Pennsylvania Department of Health to provide public health services 
through a network of regional offices and small county-based health 
centers. The national picture is different. The United States has more 
than 3,000 county and city health departments and more than 3,000 local 
boards of health (National Association of County and City Health 
Officials 2006). In the majority of states, most local public health work is 
done at a county level because prevention and protection are most often 
best done at this level.  

 From October 2004 through December 2007, faculty from the Drexel 
University School of Public Health (Drexel) collected information from 
and about the residents of four of the counties without a countywide 
health department. Drexel conducted four separate studies to assess ways 
to enhance local public health services, including the feasibility of 
establishing county health departments, in Lancaster, York, Berks and 
Dauphin Counties – which we will refer to as “the four counties.” In 
important ways, the four counties are similar. They are, respectively, the 
6th, 8th, 9th, and 15th most populous counties in Pennsylvania. They each 
have a large rural population, but each has a central city (also the county 
seat) that is a service hub for the County. The central city in each – 
Lancaster, York, Reading, and Harrisburg – is both the most populace 
place and the locus of many of the most pressing public health concerns 
in the county.    

Each of the four counties has important environmental health 
concerns related to water and air quality, ground contamination, and lead 
poisoning. Age adjusted death rates for cancer, diabetes, and stroke in 
each of the four counties exceed both the average rates for Pennsylvania 



Dennis Gallagher and Jennifer Kolker        85 
 
 
 

 

as a whole and the goals of Healthy People 2010. Drexel’s research of 
primary data sources affirmed that concerns about chronic disease and 
the lack of accessible prevention and treatment services in the four 
counties are serious issues. For example, in the most recent study, in 
Berks County, more than 60% of the persons who completed a survey 
cited the following areas of unmet need: access to health care via health 
insurance and support services; oral health education and access to dental 
care; nutrition education and counseling; and mental health education 
and treatment services.  These are all significant health service needs – 
population based needs – now going unmet or receiving inadequate 
attention and resources in Berks County.  Findings in the other counties 
were not very different. In short, improving the health of the four 
counties’ residents needs more attention than it has received via the 
current configuration of public health in Pennsylvania. We, like many in 
the field of public health, believe that the attention can be provided best 
if it were provided locally. 

The methods that Drexel used to collect and analyze information via 
targeted surveys, interviews with key informants, and common data 
sources evolved over time, but there were several elements common to 
each study. Each had five major components: 1) the analysis of 
programmatic needs and service gaps, community interest and support, 
from primary data sources; 2) the analysis of health status data and 
reports from secondary sources; 3) an assessment of programmatic 
activities, organizational structure, and financing in selected county 
health departments in Pennsylvania and Maryland; 4) the analysis of 
potential operational costs and revenues of a new countywide health 
department; and 5) the identification of next steps to build support for 
acting on the study findings and recommendations. (In the Dauphin and 
Berks County studies, Drexel also considered the technical and financial 
feasibility of non-governmental approaches to enhancing public health.)   
The methodology proved to be an effective way to identify key public 
health needs, to elicit the views of persons in the best position overall to 
comment on public health deficits in each county, and to present the 
research findings in a straightforward way.    

In many instances, the findings from the surveys and interviews were 
consistent with information Drexel collected from public data sources.   
In some instances, however, the findings – the perceptions of problems 
and issues vs. the public health “record” – were contradictory or 



86 OBJECTING TO PUBLIC HEALTH – STORIES FROM FOUR PENNSYLVANIA 
COUNTIES 

 
 

 

disconnected. Sometimes the data pointed to issues that have not yet 
been realized by the people at large – even by the one hundred (or more) 
key informants that Drexel targeted in its research in each county. In 
many instances, there is simply not enough information to know if issues 
raised in interviews and surveys are valid. This in and of itself points to a 
need for greater capacity for public health related data collection and 
disease investigation at the local level.   

Four themes emerged from Drexel’s research. First, access to 
personal health care and management of chronic disease are significant 
issues facing the residents of the four counties. Many residents have no 
regular health care provider, and residents of these counties fare worse 
than their counterparts in other parts of the Commonwealth on many 
health issues (as is clear from Department of Health data). There are 
significant disparities in health access and status by race/ethnicity as well 
as geography, with residents in the central city in each county and the far 
rural areas of the counties facing the greatest challenges. There are some 
areas of core public health, e.g., tuberculosis, STDs, lead poisoning, 
which may not be getting the resources or attention necessary to truly 
understand, prevent, and treat.   

Second, environmental health is a key issue for many, and the 
concerns expressed during the studies are in this instance supported by 
public data sources. For example, Berks County ranks poorly in 
assessments of air pollution and lead, and there are concerns about 
industrial environmental hazards and potential cancer clusters. Radon 
levels in Berks County are higher than in other parts of Pennsylvania, 
and Lyme disease is a critical issue, with rates second highest in the 
Commonwealth. The environmental health experience in the other three 
counties studied is similarly worrisome.  

Third, public health epidemiology and investigation resources are 
insufficient to meet any of the four county’s needs.  Too often, the data 
are not available to pursue or confirm the validity of health concerns 
raised by individuals and groups – and there is no readily available agent 
to collect that data and investigate in a timely and effective way. For 
example, hepatitis C was cited in Berks County as a major issue in the 
interviews and surveys of key informants, but the data on county 
prevalence of the disease are limited. This points to a major gap in public 
health epidemiology and data collection.  It also points to the need for an 



Dennis Gallagher and Jennifer Kolker        87 
 
 
 

 

agency focused specifically on the county’s experience to determine 
whether or not there is a true public health problem in the county.  Issues 
raised over cancer clusters and health impacts of environmental hazards 
would similarly benefit from a more locally focused and more expansive 
public health approach.   

Fourth, coordination of health services and leadership for public 
health is lacking within each of the four counties. Despite all the services 
that are available from the Pennsylvania Department of Health – and 
there are many – and from the many private agencies doing the business 
of public health, there is no one, clear, organizing body or focal point for 
public health activities, no “go to” place in any of the four counties. In 
each of the four counties, one organization or a network of like-minded 
organizations has stepped in to try to make up for this deficit. In 
Lancaster County, it is the United Way of Lancaster County and the 
Partnership for a County Health Department. In York County, it is the 
Healthy York Network, a component of the broader initiative, York 
Counts. In Berks County, it is the Berks County Community Foundation. 
In Dauphin County, it is the State Health Improvement Partnership 
(SHIP). These organizations and coalitions have helped to focus activity 
and attention on the public’s health within the respective counties; but 
they are not public health agencies. Because no county government 
agency has this responsibility, there is no clear authority or public 
accountability at the county level. Public health authority and 
accountability at the county level is the norm in most places in this 
country, but, as we have noted, not in Pennsylvania.   

By any accounting, each of the four counties has a rich, though 
loosely tied, public health infrastructure. Yet the services, both public 
and private, to promote and protect the health of the residents are not 
available equally everywhere in these counties, nor in some cases, 
sufficiently. The public health services provided by the Pennsylvania 
Department of Health are significant assets. But the professional staff 
resources and public health programs available to the residents of the 
four counties are significantly fewer than those available, for example, to 
the residents of the six Pennsylvania counties with countywide health 
departments.    

To gauge the contrast of the four counties’ experience with the scope 
and scale of local public health department activity in counties with 



88 OBJECTING TO PUBLIC HEALTH – STORIES FROM FOUR PENNSYLVANIA 
COUNTIES 

 
 

 

health departments, Drexel interviewed and collected information from 
the Pennsylvania Department of Health’s Southcentral and Southeast 
District Office staff and carefully analyzed the Annual Program Plans of 
Montgomery, Chester, and Erie Counties, and of the cities of Allentown 
and York. What Drexel found are public health program activities in 
these localities that go far beyond the services that the Pennsylvania 
Department of Health is able to provide locally.   

When Drexel began its first study, in Lancaster County, in October 
2004, we expected to find compelling evidence why having a county 
health department to protect a population of almost 500,000 residents 
made good sense. The needs to assure access to personal health services 
for disadvantaged persons, to investigate and ameliorate environmental 
hazards, and to prepare for and respond to emergencies are certainly 
clear – to everyone connected to the public health world, even indirectly.  
Yet this story does not sell well. It has not been sold to the majority of 
Pennsylvanians, ever. And it has not been sold, yet, in Lancaster County 
or in the other three counties we studied. An important but neglected 
reason is that the objection to public health as a local government 
undertaking has a firm and – maybe – impregnable basis. That may not 
have always been so; but after several decades of public sentiment 
largely – and sometimes aggressively – opposed to government programs 
and taxes, it certainly is the true story for many residents in the four 
counties. 

 

The Contrarian Viewpoint 

Despite clear and strong evidence for why more local attention to 
public health would benefit the residents of the four counties, the 
reaction to the idea of creating a county health department, or otherwise 
expanding public health services, has often been negative. The reasons 
fall into three general categories. The primary one is the deep and 
abiding fear of an additional tax burden, in the future if not also the 
present. A second objection is a libertarian objection to the expanded, 
intrusive presence of government in “private” business matters, and 
associated concerns about service duplication, inefficiency, and waste. A 
third is the failure to explain why a government public health agency has 
any real value at all since no crisis exists and no harm from the absence 
of one can be convincingly shown. 



Dennis Gallagher and Jennifer Kolker        89 
 
 
 

 

First, the fear of taxes. What is the money angle behind all this? – a 
question that so many wanted to raise. In fact, the fear of new taxes and 
expanded government spending seemed to live independently from any 
reality, and seemed deaf to any meaningful answer that might be offered. 
Drexel presented several organizational and financial models for each 
study. The models described county health departments ranging in staff 
size from 32 to 73, and in annual operating costs and revenue from $5 
million to $8.3 million. The variation was driven fairly equally by size of 
population and what might loosely be called “political feasibility.”  
Support for creating a county health department, based on surveys that 
Drexel distributed, varied among the four counties: 46%, 53%, 66%, and 
69%. In those same counties, in the same order, the following 
percentages of respondents were undecided about whether or not to 
support creating a health department: 40%, 45%, 30%, and 22%. Yet the 
percentage of survey respondents who said that they opposed creating a 
county health department was very small, ranging from only 2% to 9%.   

In one sense, these data make a reasonably encouraging case FOR 
creating county health departments. But the Drexel surveys were targeted 
to key informants – persons and organizations which would best 
understand the domain of public health. So we expected to see both 
understanding of the key issues confronting the county in question, and 
appreciation for the utility of a local government response to the county’s 
public health needs.  In that sense, the support shown by the respondents 
is less encouraging than one might expect – at least for two of the four 
counties. The prime reason why so many were undecided is very 
straightforward: a concern for what it might cost county taxpayers.   

For the county where interest in expanding public health services 
seemed the least (46% support), the scope and scale of county health 
department activity we modeled was kept small (52 staff and $5 million 
in operating costs and revenue). For the county where interest in 
expanding public health seemed the highest (69%), the health department 
model we developed called for a much larger organization (72 staff and 
$8.3 million in operating costs and revenue). The amount of local tax 
contribution to the total annual operating budget varied significantly as 
well, from $150,000 to $826,000 – depending on the level of support 
reported on the surveys and elicited via interviews (markers of “political 
feasibility”) more than any other variable.  Finally, the per capita annual 
local contribution – a direct draw from county tax revenue – also varied 



90 OBJECTING TO PUBLIC HEALTH – STORIES FROM FOUR PENNSYLVANIA 
COUNTIES 

 
 

 

substantially by county: $0.30, $1.00, $1.50, and $2.00. By any calculus, 
these amounts are quite small – and ridiculously so given what this small 
investment might buy in prevention, protection, and treatment. 

Drexel offered financial models that showed how reliance on local 
funding sources – taxes and fees combined – could be kept quite modest, 
in contrast to the national experience, and even more modest than is the 
case in the Pennsylvania counties with health departments. The 
opportunity to fund operations through effective use of grants (under 
Pennsylvania Acts 315, 12, and 537, and various categorical programs) is 
very real, and very significant. The table below shows national and 
Pennsylvania revenues by sources for county health departments, and 
contrasts that with the revenues that Drexel estimated for the four 
counties it studied, assuming that each would in fact establish a county 
health department (National Association of County and City Health 
Officials 2006).  

 

Table 1 

County Health Department Revenue:  All Sources 
(Percentage of Total) 

  National Pennsylvania The Four Counties 

 Federal and State Grants 36% 67% 77% 

 Local Sources   47% 23% 19% 

 Other Support 17% 10% 4% 
 

What we heard, though, was a recurring drumbeat of worries. What 
will it cost? We answered: much less than you think, and we showed 
how much. How much more will it cost in the future? We answered: no 
more than the commissioners and citizens of the county choose. What if 
the state cuts its financial support? We answered: it has not happened 
since the law enabling the creation of county health departments was 
enacted in 1951. Will we end up paying what the taxpayers in, for 
example, Chester County have to pay for their county health department 
– which started small but has grown to cost $11 million per year, with 
the county paying $1.6 million annually from county taxes (Chester 
County Health Department Program Plan 2007)? We answered, again: 
not if you don’t choose to do so. How will restaurants afford the 



Dennis Gallagher and Jennifer Kolker        91 
 
 
 

 

licensing fees, and won’t we have to pay more for the food we eat there?  
We answered: on average, food establishments would be expected to pay 
less than $200 per year in licensure if they met the county’s health code 
standards. We suggested that $200 per year per establishment would not 
have a noticeable effect on any one person’s food bill.   

And along go the many questions about money. The frustrating part 
of the process is not the many questions that are posed. The frustrating 
part is that so many people seem to reject the credibility of the answers, 
even though there are four county health departments (Bucks, Chester, 
Montgomery, and Erie) and four municipal health departments 
(Allentown, Bethlehem, Wilkes-Barre, and York) which, if studied, will 
confirm the logic and realism of the answers. Perhaps the contrarian view 
is so deeply set in the four counties we studied – and throughout the 
country – that any NOT unpleasant answer about taxes and government 
spending must be seen as lacking in credibility.   

The second objection to enhancing public health services, especially 
through a county government approach, is related to the first, but it is 
broader.  It is an objection to an expanded, intrusive presence of 
government in “private” business matters.  It is closely associated with 
concerns about service duplication, government inefficiency, and waste.  
One commentator said: “The (existing private) agencies cover everything 
that needs to be done; we don’t want duplication of services” (Drexel 
University School of Public Health 2007). Another said: “Companies are 
engaged in wellness programs (disease prevention, obesity, and smoking 
cessation) which fill the needs” (Drexel 2007). And another said: “I am a 
service provider and I am concerned that if a county health department 
were created, it could hurt the level of services that agencies like mine 
provide. If money goes to the county health department instead of to 
these agencies, the agencies might not be able to survive” (Drexel 2007).    

This point of view, correct or not, is based on a suspicion of 
government itself. This distrust seems to go deep. We sensed – and 
sometimes were told – that a county health department would certainly 
find public health problems, like lead and groundwater contamination.  If 
the county looked and found such things, property owners and businesses 
would be forced to fix the problems. The focus then becomes fixed upon 
enforcement by a hypothetically nosey, arrogant, untrustworthy county 
agency, not on the threat to public health and safety. We tried to make 



92 OBJECTING TO PUBLIC HEALTH – STORIES FROM FOUR PENNSYLVANIA 
COUNTIES 

 
 

 

the case that enhancing local public health was about protecting little 
children, not building big government. But the suspicion remained.   

We recommended in one study that a concerted effort be made to 
develop relationships with the region’s major businesses based on the 
business interest in having a supply of healthy workers in the 
community. We referenced a recent article from Health Affairs by Paul 
Simon and Jonathan Fielding entitled “Public Health and Business: A 
Partnership that Makes Cents.” The authors make a strong case.  
“Businesses should have a financial interest in supporting organized 
public health efforts, and collaborative efforts can increase the reach and 
effectiveness of public health” (Simon and Fielding 2006). We saw this 
“business case” as one way of confronting an innate anti-government 
bias on the part of many. 

We heard this bias expressed about restaurant inspections, in 
particular. Owners we interviewed objected to having to comply with 
new codes and county inspectors. That is not surprising. But some 
citizens – even some commissioners – who are connected to restaurants 
only as patrons also objected to more frequent and more comprehensive 
restaurant inspections. The general view is that food service 
establishments that are unclean and unsafe will not be patronized. The 
corollary, we must suppose, is that popularity (in the view of some, 
maybe many) is an empirical assurance of safe and sanitary food 
handling. As one commentator from York County noted: “Have we had 
outbreaks of food poisoning linked to restaurants that the media has 
failed to report?” (Dunn 2006). Of course, the answer might well be: who 
knows? Yet we were told bluntly on several occasions that county 
government should not get into the business of food service inspections, 
period. This seemed especially shortsighted for communities that 
depended economically on tourism and, in turn, on their reputations as 
inviting, safe places to visit – and in which to eat. 

The last major objection is the lack of hard, local evidence to 
demonstrate why and how a government public health agency has any 
real value at all. If no crisis exists, then no harm from the absence of one 
can be shown. It is as though no local police are needed because no 
crimes are being committed. No local fire department is needed because 
no homes or businesses are on fire. Of all the objections, this is the 
hardest to overcome because there are no numbers, no symbols, no 



Dennis Gallagher and Jennifer Kolker        93 
 
 
 

 

stories that make a compelling case for more public health at the local 
level when there is no sense of an actual or looming threat. As one 
commentator said, “I travel all over the county and have heard nothing 
about the need for public health services of any kind” (Drexel 2007).  

Playing into this last objection is the urban-rural divide in each of the 
four counties. The health and social problems in Lancaster, the cities of 
York, Reading, and Harrisburg, are viewed by many as the problems of 
the poor and minorities only. The deep divides along racial and 
socioeconomic lines, embodied geographically in the differences among 
those cities and the surrounding suburbs, outlying towns, and rural 
communities, constitute a psychological firewall for many of the 
majority population. That’s a Harrisburg problem, or a Reading problem.  
We often heard that. The logic is that there is no public health threat in 
the county if the threat is contained within the poor populations of the 
central cities. And so there is no need for a county health department that 
taxpayers outside those cities need to support. 

As one cogent commentator in York County noted, “The idea of a 
county health department has been around for at least 40 years. It never 
gained any significant support in the past, probably because no 
significant need was ever identified” (Dunn 2006). That commentator 
went on to say that the need for more effective immunization programs 
was not demonstrated because there have been no “disease outbreaks 
resulting from the lack of such programs” (Dunn 2006). This 
commentator was not expressing an anti-government bias. He noted that 
“over the past 40 years … highly successful county programs have come 
into being. These include planning, solid waste disposal, parks and 
recreation. In all of these cases, unmet needs were (first) identified” 
(Dunn 2006) – and so county government intervention was warranted.  
Not so with and for public health – precisely because its value lies 
preeminently in its prevention ethos. If you do not envision prevention as 
an unmet local need, you will not buy into the idea that local public 
health matters.  

 

Confounding the Contrarians – Can It Be Done? 

In the four studies that Drexel completed, we tried to assess how 
much – and how little – local conditions affect the perceptions of both 



94 OBJECTING TO PUBLIC HEALTH – STORIES FROM FOUR PENNSYLVANIA 
COUNTIES 

 
 

 

public health needs and the opportunities for enhancing county-based 
and countywide programs. Public health issues for residents of Lancaster 
County bear a resemblance to the issues for residents of Berks County, 
for example.  Issues facing the residents of the four central cities are very 
similar – all connected to racial and ethnic health disparities, and 
poverty. Issues of remoteness and too few health and social services 
facing residents in the northwest and southeast communities of York 
County are not unlike those facing residents of southeastern Lancaster 
County and upper Dauphin County. The stories from the four counties 
sound similar, but they are still different enough to help make the case 
for why public health is best understood within a very local context.   
The politics are different. The health care organizations interested in – 
even committed to – local public health are focused on the specific needs 
of their surrounding community. The key to answering the contrarian 
views is to know in fine detail the unique features of the issues faced by 
the different communities. That is something that only local people, local 
institutions, local collaborations can undertake.   

 From a distance, Drexel offered several generic but very real reasons 
for why the stakeholders in the four counties should build a more 
effective local public health presence. Creating a county health 
department, for example, would have several tangible benefits. It could 
bring into each of the four counties more than $1 million in additional 
state categorical grants, and more than $2 million of Acts 315/12/537 
state grant support to benefit county residents. Put another way, each of 
those four counties annually foregoes more than $3 million that could go 
directly to public health programs targeted to the needs of the residents if 
it does not create a county health department. Creating a county health 
department would also likely ensure: 

 More effective standards setting and consistency in overseeing public 
health matters (communicable disease surveillance, disease prevention, 
inspection, and licensure of food service establishments, environmental 
health, etc.). 

 More effective county-wide coordination of public health related 
services, by municipalities, school districts, hospitals, and other non-
profit private agencies. 



Dennis Gallagher and Jennifer Kolker        95 
 
 
 

 

 More effective local control and priority setting through more effective 
leadership of health-related matters at the county level. 

But one final question always remains: if having a county health 
department is such a great idea, why have so few Pennsylvania counties 
established one – especially since Act 315 was passed in 1951 to do just 
that? 

 There are likely several answers, all of which make the argument for 
why there should be more local public health presence in Pennsylvania a 
particularly hard one to win. Few in Pennsylvania really understand or 
care about public health, unlike in Maryland, New York, Michigan, 
North Carolina – and many other places throughout the United States.  
There are several possible reasons. First, medical schools and hospitals 
dominate the health world in Pennsylvania. Perhaps, in turn, because of 
this institutional medical dominance, except for the University of 
Pittsburgh, there have been no schools in Pennsylvania devoted to 
studying public health and encouraging its expansion, until the Drexel 
School of Public Health was established a decade ago.   

 Second, as we described above, there really is an abiding fear about 
government intrusion in private and business matters, and the costs 
associated with that intrusiveness. This is especially so in the less 
urbanized parts of Pennsylvania – meaning, most of it.  

 Third, we have been relatively lucky in terms of avoiding food borne 
and communicable disease outbreaks. It might also be that outbreaks are 
undercounted precisely because there is no consistently designated 
authority who the public knows to contact when a food borne illness 
occurs. In either case, there is insufficient regard and caution in the 
public mentality about such threats – and about the associated risks we 
then bear in having inadequate inspection, surveillance, and response 
systems. 

 The last point is important because if that changes, all of the 
contrarian arguments could be overcome. For similar, but less urgent and 
scary reasons, that is how the Montgomery County Health Department 
got started: concern (among a few committed doctors at first) about 
responding to Lyme disease, rabies, and HIV/AIDS – at a critical, 
challenging point in time, 1989-1991. That fear or concern can be 
enough of a tipping agent to change the balance. Anyone promoting an 



96 OBJECTING TO PUBLIC HEALTH – STORIES FROM FOUR PENNSYLVANIA 
COUNTIES 

 
 

 

enhanced local public health presence needs to be mindful of that. But 
prevention is a hard sell, and until recently, so was preparedness.   

 We must also acknowledge that “selling” the need for more local 
public health presence is compromised by our inability to make a sure 
case for how and why a county health department improves the 
population’s health in a clearly demonstrable way. It’s what we call the 
“It’s a Wonderful Life” test. If the “XYZ” county health department did 
not exist, could we clearly see how the population’s health would be 
dramatically worse off? Can anyone REALLY show what the precise 
effect a county health department has on a population’s health – in the 
same way that George Bailey was shown how his life mattered so much 
to so many in Bedford Falls? We asked that question, informally, of 
persons who work in county health departments, and we were given fine, 
but modest answers. None of the answers were so dramatic that they 
would “make the sale” for local public health to a community full of 
committed contrarians – not in our view. 

 At the end of the day, selling public health at the local level must be 
built upon, and carried along by, some authentic and pointed message of 
prevention and protection – just like the need for more local police is 
promoted. It must be a message about being closer geographically, about 
knowing the community intimately, and the community knowing where 
it can turn for help. It’s likely the only way to confound – if not silence 
or convince – the public health contrarians who reside throughout 
Pennsylvania, both average citizens and elected officials. 

 

References 

Chester County Health Department Program Plan 2007-2009. 

Chowdhury, Pranesh P., Lina Balluz, Wilmon Murphy, Xiao-Jun Wen, Yuna Zhong, 
Catherine Okoro, Bill Bartoli, Bill Garvin, Machell Town, Wayne Giles, and Ali 
Mokdad. “Surveillance of Certain Health Behaviors Among States and Selected 
Local Areas.”  MMWR, May 11, 2007/56(SS04); 1-160. 

Drexel University School of Public Health, Health Department Feasibility Study: Berks 
 County, Pennsylvania, December 2007. 

Dunn, Jack. “Do we Really Need a County Health Department,” York Daily Record, 1 
January 2006. 

National Association of County and City Health Officials. 2006. 2005 National Profile of 
 Local Health Departments.  



Dennis Gallagher and Jennifer Kolker        97 
 
 
 

 

Simon, Paul A. and Jonathan E. Fielding. 2006. “Public Health and Business: A 
 Partnership that Makes Cents,” Health Affairs, 25, 4, 1029. 

U.S. Department of Health and Human Services, Healthy People 2010. 



Commonwealth:  A Journal of Political Science       Volume 14, Number 1      December 2008 
Special Policy Issue on Public Health             2008 PPSA/LORL, PA House of Reps.  ISSN 0890-2410 

 

 


