Local Responses to Limits on U.S. Public Health Authority During the COVID-19 Emergency.

Public health has become politicized in the U.S. Though research shows that limiting public health authority during emergency response puts community wellbeing and health outcomes at risk, during the COVID-19 emergency (2020-2021), some U.S. state policymakers limited the disease-preventing actions local public health agencies could take. This conflicts with public health agencies' mandate to protect lives. Using COVID-19 as a case study, we explored how local public health agencies upheld their mandate when faced with limited public health authority. We conducted qualitative semi-structured focus groups (October 2023) with a purposive sample of U.S. public health officials (n = 14) from seven U.S. states which experienced four types of restrictions on local public health actions (limits on the emergency authority of governor, chief executive, state health officer, and local government health officers). Participants discussed barriers and challenges faced, adaptations made, actions taken, and perspectives for the future. Emergent themes suggest that while limited resources and restricted public health authority caused strain, public health efforts were upheld through cross agency collaboration at the local level which supported innovation. To achieve this, trust-building and communication were vital. Limitations on local public health authority may increase in the U.S. in the coming years. To mitigate risks amidst future public health emergencies, public health leaders must focus on building trust, clear and consistent communication, and bolstering collaborative networks at the local level. The politicization of health policy at the state and federal level also needs to be addressed, as local action can only go so far.