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


Shaw, S.J. Governing How We Care: Contesting Community and Defining Difference in U.S. Public Health Programs . Philadelphia : Temple University Press , 2012 , 226 pp $27.95 (pbk) ISBN : 1-4399-0683-1 , $84.50 (hbk), ISBN:  1-4399-0682-3 , $27.95 (ebk) EAN: 978-1-43990-684-2

In Governing How We Care, anthropologist Susan Shaw offers a sophisticated critical examination of community health efforts in the United States. Grounded in many years of ethnographic research across several different public health settings in the Massachusetts, Shaw examines ‘state and nonstate actions designed to “ethicalise” health care (Rose 1998: 91) by expanding access to healthcare, addressing cultural differences in the clinic, and preventing HIV among people who use injection drugs’ (Shaw 2012: 18). Theoretically, her work is organised around Foucault’s theoretical construct of ‘governmentality’ and ‘explores the knowledge formations and sets of practices that together work to construct and govern populations and subjects’ inherent in federal and state government-sponsored community health initiatives.

In the first part of her book, Shaw focuses on select initiatives within the publicly funded community health centre system to improve care for socially marginalised populations, particularly communities defined by race and/or ethnicity. She draws on her own work experience as well as rich ethnographic observational and interview data from programmes designed to train lay people to conduct community outreach and to promote greater cultural sensitivity and cultural competence among healthcare providers. Because her research extended over many years, her analysis is historically rich as she observed first hand many changes that resulted from reforms associated with the federal Welfare to Work initiatives launched in the mid-1990s.

Her analysis is nuanced and intriguing. In the name of caring for the vulnerable, community health programmes in practice define communities in terms of both traditional sociopolitcal divisions (e.g., race/ethnicity, socioeconomic status) and health risks. These new social categories, Shaw argues, have had important social and political consequences. On the one hand, from the perspective of the targeted communities, they have created new, culturally legitimate avenues for socially marginalised groups to express their needs and demand social justice. At the same time, they have also defined new objects for formal governmental action and helped to justify and promote a neoliberal governmental agenda that both acknowledges social injustices but also facilitates placing greater responsibility on vulnerable individuals and communities for effecting real change.

This basic theme is examined in different ways in the second part of the book which examines the internal workings of needle exchange programmes designed to prevent HIV/AIDS among injection drug users (IDUs). Here again, Shaw’s analysis highlights the logical contradictions inherent in the structure of public health programmes. On the one hand, efforts to better target HIV prevention interventions have led to a proliferation of new categories of risk and an expansion of prevention-related services for IDUs and other people engaging in HIV risk-related behaviours. Yet, efforts to improve and expand prevention programming and reach those ‘most at risk’ also have served to reinforce HIV-related stigma and strengthen the neoliberal policies of state and federal government that assign more responsibility to the individuals that these programmes are designed to help.

Shaw’s book is interesting and provides an insightful critique of public health programming in the United States. She demonstrates both the contested nature of what these programmes do and the definitions of the communities that they are intended to serve. The book will no doubt be of interest to sociologists, anthropologists, and other social scientists interested in societal responses to health problems. It is well written and deeply grounded in contemporary social theory and careful analysis of rich and varied ethnographic data. While social theorists and ethnographers will find the book a valuable contribution to the field, public health practitioners may be disappointed. Shaw’s critique is clear and significant, but she does little to explore the implications of her analysis or provide concrete recommendations for improving public health policies or programmes.