The fight for the public’s health is a struggle for true democracy

This piece is part of a narrative series around the case for co-governance led by Race Forward and Partners for Dignity and Rights.

As the United States continues in its 250th year, public health is part of a broader national reckoning about democracy, what it means to be free, and on how power is shared and exercised. If the future of health equity is our goal, then the way governance itself is built must be addressed: who sets priorities, who gets to decide, and who is invited to the table.

This is especially true at a moment when rising authoritarianism is threatening our democratic institutions and our public health infrastructure. Co-governance—defined as “government and communities working together through formal and informal structures to make collective policy decisions, co-create programs to meet community needs, and make sure those policies and programs are implemented effectively”—can guide the way to achieving our collective goal of public health for all.

This commentary is part of a series on the case for co-governance and offers an antidote that can move us closer to a healthy future and the elusive promise of a multiracial democracy.

Lessons from the COVID-19 pandemic

As public health workers, we’ve seen firsthand how community power-building and deep partnerships between government and community organizations can create the conditions needed for both collective health and for democracy. And for a brief moment we saw glimpses of hope, in response to the COVID-19 pandemic, toward meaningful transformation: a society organized around collective care, where local, state and national governments took bold action to protect health, and communities mobilized to support one another.

If the future of health equity is our goal, then the way governance itself is built must be addressed: who sets priorities, who gets to decide, and who is invited to the table.

These glimpses appeared in the creation of community mutual aid networks, the sharing of resources with those who needed them most, and the passage of policies that once seemed politically impossible, such as eviction moratoria, unrestricted cash assistance, and decarceration. During this time, many public health workers took part in the 2020 racial justice uprisings and many local governments declared racism a public health crisis.

But the backlash to these advancements has been fierce. In recent years, we’ve seen a return to hyper-individualism, the extractive accumulation of wealth by billionaires, and the rise of authoritarianism. This ideology is eroding the foundations of our democratic systems and dismantling our core public health infrastructure through the removal of thousands of workers at federal health agencies, funding cuts, and an end to essential programs and services.

When a government becomes authoritarian, public health can either become a tool of harm or a force for collective liberation. Though our current situation is dire, there are reasons to believe public health can continue to be leveraged as a nonpartisan force for good. It already offers us many examples of what co-governance can look like as a practice towards ensuring our collective health and our democratic freedom.

Partnerships between health departments and community organizations matter

Earlier this year, Health in Partnership (HIP) published Bridges Over Troubled Water, a national landscape assessment of partnerships between health departments and community power-building organizations. The report identified 71 examples of these partnerships and found that many emerged from racial equity collaborations during the pandemic and then expanded to address broader policy issues.

Some of these partnerships have participated in HIP’s Power-building Partnerships for Health (PPH), a program to develop inside-outside strategies between local governments and social movement organizing to take collective action towards health equity and racial justice. HIP has had the honor of working closely with 26 PPH partnerships over the past decade—and the impact has been substantial.

An inside-outside strategy is simple in principle and radical in practice. “Inside” government partners become institutional accomplices rather than gatekeepers, while “outside” organizations become leaders rather than participants. Together, they build models of co-governance grounded in shared decision-making, accountability, and community power.

While each partnership is unique, we’ve seen a key throughline: Community power creates the conditions needed for health equity and democracy.

When a government becomes authoritarian, public health can either become a tool of harm or a force for collective liberation.

For example, the New Orleans Health Department (NOHD) first partnered with the community power-building organization Step Up Louisiana (now known as ONE, Organizing for a New Economy) during hurricane response efforts, and later deepened that partnership during the COVID-19 response. NOHD identified economic inequality as a driving force for health outcomes in its Community Health Improvement Plan and collaborated with Step Up/ONE to support its Workers Bill of Rights campaign. The  campaign passed in November 2024 with 80 percent voter approval, which allowed them to modify the city charter and create a Healthy Workplace Program that essentially rewards employers that prioritize living wages, access to healthcare, paid leave, and the freedom to organize.

In Jackson, Mississippi, the Jackson People’s Assembly created a process for deep democracy via political education, collective decision-making, and co-governance. Through PPH, the partnership between Jackson’s Peoples Advocacy Institute and the University of Mississippi Medical Center is implementing the People’s Assembly agenda with community-led solutions to violence and public safety. In Lansing, Michigan, One Love Global has hosted the Lansing People’s Assembly since 2020 and worked with the Ingham County Health Department around the county’s declaration of racism as a public health crisis.

These examples show how community organizers and public health practitioners can coordinate and respond to the crises of our times.  From the Latinx Indigenous Migrant Health COVID-19 Task Force protecting farmworker health in Santa Barbara, California, to the National Day Laborer Organizing Network‘s more recent efforts to respond to the Los Angeles wildfires while protecting workers from hazards, and Community Organizing and Family Issues expanding mental health and peer support for immigrant families in Kane County, Illinois—there are many models for public health and community power-building organizations to develop shared inside-outside strategies.

Why co-governance matters for the future of public health

Co-governance makes government accessible and accountable to those it serves. During periods of democratic backsliding, the presence of institutional actors who refuse to uncritically follow authoritarian directives creates space for peoples’ movements to defend rights, protect communities, and win meaningful change.

Working through crises alongside social movements is not new for public health. The field emerged at the intersection of social movements, sanitation struggles, and community organizing from settlement houses movement of the late 1880s, clean water campaigns in the 1970s, and more recent healthy housing codes. As public health professionalized, it distanced itself from grassroots power, yet over the past few decades, many of us have worked alongside community organizers to push the field toward equity. The pandemic further exposed gaps while clarifying that our field’s legitimacy depends on its relationship with communities.

Today, public health sits at a crossroads. The field has technical authority, convening power, agenda-setting influence, and a stated commitment to community well-being. Public health also touches many of the material conditions that shape health, including housing, education, workplaces, and public spaces, which makes it a natural partner for community power-building organizations seeking systems change.

In our report Bridges Over Troubled Water, we identified that health departments collaborating with community partners can be a transformative practice that can both require and result in cultural and institutional shifts within agencies that change public health work by shifting and sharing power with local partners. Once an agency gets started down this path, it opens the door for a power-building ecosystem and resilient relationships that can weather the ups and downs of funding cycles. But that access must be wielded with humility, respect, and true power-sharing: Communities must lead, while public health’s role is to amplify, resource, and help translate community demands into durable policy with shared ownership.