Governing How We Care: Contesting Community and Defining Difference in U.S. Public Health Programs

Introduction

Introduction W hen I was an ethnographer for a federally funded study on HIV risk and needle use, I met Dave Wood, a middle-aged, slightly built African American heroin user who spent many of his days circulating through a neighborhood shopping plaza where people would arrive to get their morning coffee at McDonald’s, pick up a loaf of bread at Sav-A-Lot, or buy and sell drugs in the parking lot. Dwayne Rogers, the outreach worker who was my partner on the study, introduced me to Wood. They had known each other for many years, starting from Rogers’s own drug-using days when he spent time in that parking lot trying to hustle enough money for a fix. As a person in recovery and outreach worker for the project, Rogers served as a critical liaison between me and the people I was interested in recruiting as participants. In our first interview, Wood, like many people, worked hard to avoid being identified with a stigmatized group like injection drug users (IDUs), articulating a view of drug users that is clearly informed both by popular stereotypes and by the knowledge effects of the sort of research we were engaged in. Wood commented: See, you have different levels of people who use drugs. Like, . . . the guys I hang out with aren’t the ones who are out on the street, the kind of people that you know, that you see always trying to scrape up ten dollars—you know, the kind of people you probably have interviewed, I should have put it that way. You know, you got people out there every day, they struggling 2 / Introduction to survive and they look all greasy [narrows his eyes]. . . . People like that, they gotta be out there every day to get their twenty dollars for their drugs. See, I don’t have to do that. Wood’s description of “the kind of people that [we] know” as state-funded ethnographers points to the complex processes involved in the production of difference through community health research. Wood’s assertion that he was not among those who scrambled to get money to support a habit was particularly ironic, because over the course of many months I saw Wood engaged in exactly such activities in the Sav-A-Lot parking lot. One of his hustles might involve taking fifteen dollars from another user to buy her a bag of heroin for ten dollars and keeping five dollars as a “finder’s fee,” or he might do an in-depth interview with an ethnographer studying HIV risk in urban injection drug–using populations, receiving a twenty-dollar stipend for his participation. Wood’s view of “the kind of people [we] know” and his effort to differentiate himself from them reveal more than the easily understood desire to distance oneself from an oft-disparaged group. His assertions also hint at the new subject-positions that are created for both researchers and participants as service delivery and disease surveillance converge in federally sponsored drug research. Thornton,1 where this fieldwork took place, is one of many deindustrialized New England towns and cities bypassed by the booming economy of the 1990s, whose fortunes have continued to decline since the departure of manufacturing jobs beginning in the 1970s. With the abandonment of the inner city, low-income and minority Thornton residents have experienced increasing poverty and health inequalities as indexed by an expanding HIV epidemic, especially among IDUs. African American and Latino community-based organizations have worked to politicize health inequalities such as disproportionate infant mortality or HIV rates in minority communities, drawing together diverse stakeholders under the banner of community health. This book tracks the history of several of these interventions to investigate community health as a key site in which public and scholarly ideas about racial and economic difference are elaborated . As advanced liberal government increasingly depends on the emergence and identification of populations as its mode of governing (Dean 1999), community health research plays a critical role in constituting those populations frequently deemed a “problem” for governing: the poor, minorities, and those who are socially or sexually marginalized. The case studies presented here show how community health research contributes 1. This is a pseudonym, as are all names of people, organizations, and places presented as part of the ethnographic data. I consider questions of anonymization at greater length later in this chapter. Introduction / 3...