What is the role of the 911 ambulance in the American city? The prevailing narrative provides a rather simple answer: to save and transport the critically ill and injured. This is not an incorrect description, but it is incomplete. The ambulance plays another role, one that is less known. Along with other frontline institutions like the prison and welfare office, I argue the ambulance is part of a regime of poverty management that is focused more on processing docile and industrious subjects than on eradicating material deprivation.
I draw on nearly two years of fieldwork (including 9 months working as a novice emergency medical technician) and thousands of medical records to reimagine the ambulance as an institution of poverty governance. Against somewhat common assumptions that the ambulance is absent or tardy in poor neighborhoods, my research demonstrates that the ambulance is actually a prevelant and busy institution in these areas. Not only are the poor more likely to experience life threatening crises, they are also more likely to summon the ambulance for so-called non-emergencies.
Whether by compressing lifeless chests on the streets or by transporting the publicly intoxicated into the hospital, ambulance crews daily transform the bodies and spaces of urban poverty. This work brings them in recurrent contact with the emergency department nurses and police officers who share their clientele. I show how these different workers often conflict over the management of subjects they generally see as burdensome. With “legit” ambulance calls being relatively rare, crews frequently struggle with police, nurses, and even firefighters over “bullshit” work. These street-level relations, however, cannot be understood without considering the forces from above that control and coordinate labor. Neoliberal principles of organizational efficiency and flexibility have flooded poverty governing institutions throughout the American city, and the ambulance is no exception. The state often delegates paramedical operations to for-profit agencies that run on a fee-for-service model. This translates into intensified exploitation of crew labor and exacerbates tense relations between crews and their clientele on the one hand and crews and their nurse and police counterparts on the other.
My research motivates a new framework for understanding the management of marginality: the labor theory of poverty governance. This model insists that we cannot understand how the poor are governed without understanding the labor process that generates and re-generates the poverty regulating state. This means accounting not only for the interactions between laborers and the subjects of their labor, but also the horizontal interactions amongst laborers and the vertical interactions between laborers and those who control and coordinate their work.
2017 James D. Thompson Graduate Student Paper Award. American Sociological Association’s Organizations, Occupations, and Work Section.
Abstract: This article reimagines poverty governance as a labor process. Extending theories of bureaucratic fields and street-level bureaucracies, the proposed model suggests that the state manages the poor through fragmented activities embedded in horizontal and vertical relations of production. I use an ethnography of 911 ambulance operations in a single California county to advance this perspective. From plugging gunshot wounds to moving sidewalk slumberers, ambulance crews interact with a mostly impoverished clientele base by transforming spaces in bodies and bodies in spaces. This two-sided governance puts the ambulance in recurrent contact with the hospital emergency department and the police squad car. Across these institutions, ambulance crews struggle with their nurse and police counterparts over the horizontal shuffling of burdensome work, shaping the life chances of their subjects in the process. At the same time, bureaucratic and capitalistic forces from above activate a lean ambulance fleet that is minimally wasteful and highly flexible. This verticality structures clientele processing through the ambulance and fuels tensions across the frontlines of governance. In an effort to advance theory and fill an empirical gap, this article proposes a new model for understanding the management of marginality and highlights an overlooked case of poverty regulation.
Abstract: Background: Neighborhood poverty is positively associated with frequency of 9-1-1 ambulance utilization, but it is unclear whether this association remains significant when accounting for variations in the severities and types of ambulance contacts. Methods: We merged EMS ambulance contact records in a single California county (n = 88,027) with data from the American Community Survey at the census tract level (n = 300). Using tract as a proxy for neighborhood and negative binomial regression as an analytical tool, we predicted 16 outcomes: any ambulance contacts, ambulance contacts stratified by three intervention severities, and ambulance contacts varied by 12 primary impression categories. For each model, we estimated the incident rate ratios for 10 percentage point increases in tract-level poverty while controlling for geographic patterns in race, citizenship, gender, age, emergency department proximity, population density, and population size. Results: Our study produced three major findings. First, tract-level poverty was positively associated with ambulance contacts. Second, poverty was positively associated with low severity contacts, medium severity contacts, and high severity contacts. Third, poverty was positively associated with 12 primary impression categories: abdominal, altered level of consciousness, cardiac, overdose/intoxication, pain, psych/behavioral, respiratory, seizure, stroke, syncope/near syncope, trauma, and general weakness. Conclusion: Our study suggests poverty is a positive, strong, and enduring predictor of ambulance contacts at the neighborhood level. The relationship between neighborhood poverty and ambulance utilization should be considered at multiple levels of EMS decision making.
Abstract: Roughly 700,000 people are released from American prisons every year, yet we know little about their ground-level experiences at or near the moment of exit. This ethnographic study fills part of the gap by examining the aspirations and corresponding actions of soon-to-be-released prisoners, “short-timers.” While previous research suggests this population wants a “successful reentry,” few have detailed such a desire beyond its obvious mismatch with life chances. I show that in addition to verbalizing lucid hopes and plans for the “straight life,” short-timers act in reference to these aspirations while incarcerated by drawing on two meager resources: family and penitentiary. Such aspirations and actions are not markers of ignorance. Instead, I argue that they signal a practical orientation in a world where staff dominate inmates. In friction with the durable forces of inmate objectification, short-timers can use future-oriented perceptions and practices to realize some degree of selfhood. Meanwhile, their custodians, who are never committed to despotic control or total mortification, impose complementary lessons in personal responsibility through the discourse of prisoner reentry. Besides spotlighting a rarely studied moment in prison, I offer a model for how prisoner subjectivity emerges as both a rejection and product of penal power.
WORKS IN PROGRESS (drafts available)
Seim, Josh, Melody Glenn, Joshua English, and Karl Sporer. “Neighborhood Poverty and 9-1-1 Ambulance Response Times.” (under review)
Abstract: Background: Are 9-1-1 ambulances relatively late to poorer neighborhoods? Research suggesting so often rely on weak measures of neighborhood (e.g., postal zip code), limit the analysis to particular ambulance encounters (e.g., cardiac arrest responses), and do little to account for variations in dispatch priority or intervention severity. Methods: We merged EMS ambulance contact records in a single California county (n = 87,554) with tract-level data from the American Community Survey (n = 300). After calculating tract-level median ambulance response time (MART), we used ordinary least squares (OLS) regression to estimate a conditional average relationship between neighborhood poverty and MART and quantile regression to condition this relationship on 25th, 50th, and 75th percentiles of MART. We also specified each of these outcomes by five dispatch priorities and by three intervention severities. For each model, we estimated the associated changes in MART per 10 percentage point increase in tract-level poverty while adjusting for emergency department proximity, population density, and population size. Results: Our study produced three major findings. First, most of our tests suggested tract-level poverty was negatively associated with MART. Our baseline OLS model estimates that a 10 percentage point increase in tract-level poverty is associated with almost a 24 second decrease in MART. Results from our quantile regression models provided further evidence for this association. Second, we did not find evidence that ambulances are relatively late to poorer neighborhoods when specifying MART by dispatch priority. Third, we were also unable to identify a positive association between tract-level poverty and MART when we specified our outcomes by three intervention severities. Across each of our 36 models, tract-level poverty was either not significantly associated with MART or was negatively associated with MART by a magnitude smaller than a full minute per estimated 10 percentage point increase in poverty concentration. Conclusion: Our study challenges the commonly held assumption that ambulances are later to poor neighborhoods. We scrutinize our findings before cautiously considering their relevance for ambulance response time research and for ongoing conversations on the relationship between neighborhood poverty and prehospital care.
Seim, Josh and David Harding. “Parolefare: Poverty Governance, Post-Prison Supervision, and Low Wage Work.”
Abstract: A fragmented American state governs the poor in part by managing their exclusion and regulating their exploitation. Many scholars pin a governance of exclusion to the penal state and a governance of exploitation to the workfare state. We consider how these regulatory strategies might coexist within institutions by turning to parole, an institution that seems to blend the architectural and administrative features of the penitentiary and the welfare office. Drawing on a series of correctional, employment, and arrest records for a cohort of working age formerly imprisoned people in Michigan, we show that parole generally supervises a jobless population, but it also governs a significant number of people who work in the formal economy. We also find that parole supervision increases the odds of employment across a number of industries. However, we do not find convincing evidence that parolee employment alleviates individual poverty or reduces the odds of recidivism. These results inspire a conceptualization of “parolefare,” another regime that successfully motivates worker-citizenship but does little to extend or protect the life chances of the poor.