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

1. The Governmentality of Community Health

1 The Governmentality of Community Health G overnmentality, as defined first by Michel Foucault (1991) and elaborated by subsequent social theorists and anthropologists (e.g., Inda 2005; Ong and Collier 2005), explores the knowledge formations and sets of practices that together work to construct and govern populations and subjects. Drawing on the case studies that follow, I contend that community health practices represent a privileged site for examining the “conduct of conduct”—the norms, etiquette , and behavior of individuals and populations—because the populations targeted by community health interventions are constituted, in part, by their difference. As health care and prevention are increasingly imbricated in a wide range of social practices (Briggs 2003), and as the United States undergoes yet another paroxysm of health care reform, community health research and practice are becoming key arenas in which new forms of subjects are produced. This book explores state and nonstate actions designed to “ethicalize” health care (Rose 1998, 91) by expanding access to health care, addressing cultural difference in the clinic, and preventing HIV among people who use injection drugs. To carry out this analysis, we must first consider how health policy and practice, including community organizing around health issues, can be a site for the production of subjects. This chapter discusses the diverse meanings of ethnicity and community that contribute to the formation of the field “community health,” including constructions of ethnicity as a category of governing. This work extends the anthropological concept of biosociality (Rabinow 1996) to understand the ways The Governmentality of Community Health / 19 in which marginalized groups mobilize, using health issues as a fulcrum and inequality as the lever to shift structures and their alignments that lead to their immiseration. In the chapters that follow, we see a range of community groups present health disparities arguments as a key means of circulating and disseminating claims for resources and recognition. This chapter discusses the main theoretical concepts that run through all three case studies. Research and health promotion practices enable the government of citizen-subjects, forming new subject-positions such as the public health outreach worker and the ethical drug user (Campbell and Shaw 2008). Questions of everyday practice make up the heart of the material under investigation here, as I shift the lens of biosociality from people’s interactions with the knowledge and technologies of biomedicine to the city street, where those with less access to health care contest their exclusion using the language of health disparities. Community activists, including public health workers and former drug users, establish organizations and programs designed to improve health access as a means of instantiating the very communities such programs hope to serve (Crehan 2006). In tracing these developments, I follow the direction pointed out by Nikolas Rose in Powers of Freedom (1999). A “historian of the present” regards current social configurations as “an array of problems and questions, an actuality to be acted upon and within by genealogical investigation” (1999, 11). The historian of the present examines those “configurations of the minor” (1999, 31)—the small changes in drug users’ behavior, for example, recommended by the U.S. Centers for Disease Control and fostered by harm reduction programs to limit HIV infection—which illuminate broader social trends such as the increasing emphasis on individual responsibility for health and prevention. By tracing the networks in which actors (agencies , health care providers, neighborhoods) act, examining the resources they use, and identifying the circumstances that shape their actions, this book offers an empirical examination of the social and economic changes taking place in the way government happens. Community Health and the Production of Difference In anthropology, history, and social theory, a wide body of scholarship has described the clinic as a site for the production of subjectivity (e.g., Foucault 1975, 1991; Kleinman 1980, 1988; Scheper-Hughes and Lock 1987, among many others). Medical expertise combines with state power and authority to create categories that subjects come to inhabit, such as “person with AIDS,” breast cancer survivor, or homosexual (Foucault 1978; Glick Schiller, Crystal, and Lewellen 1994; Treichler 1989; Klawiter 2008; Lorway, Reza-Paul, and Pasha 2009). However, far less has been written on the production of ethnicity in the clinic. In their book Ethnicity, 20 / Chapter 1 Inc., anthropologists John and Jean Comaroff outline three recent factors that contribute to the increased visibility of “the presence of ‘others’ within” the nation-state (Comaroff and Comaroff 2009, 46): the global...