This blog post originally appeared on the USC Equity Research Institute blog, and it is reproduced here with permission.
By Josh Seim, author of Bandage, Sort, and Hustle: Ambulance Crews on the Front Lines of Urban Suffering
Suffering seems to obey a kind of social gravity in the polarized city. Capitalism, racism, and other systems of domination and exploitation tend to pull sickness, injury, and other hardships toward the bottom of the urban hierarchy. We have known about this since the writings of Friedrich Engels and W.E.B. Du Bois, and today a plethora of studies in sociology, anthropology, and public health confirm the downward distribution of morbidity and mortality in the capitalist and racist metropolis.
In my book, Bandage, Sort, and Hustle: Ambulance Crews on the Front Lines of Urban Suffering, I seek to understand the role that the 911 ambulance plays within this context. Bandage, Sort, and Hustle isn’t a book about absent or tardy ambulances, nor is it a book about medical exclusion. Rather, it’s a book that details how paramedics and emergency medical technicians (EMTs) confront a mixed and endless stream of suffering bodies in the city’s most destitute and stigmatized territories.
Drawing on field observations, medical records, and my own experience as a novice EMT, I examine a single for-profit 911 ambulance provider in an unnamed California county. My primary goal is to better understand how ambulance crews contribute to what sociologists sometimes label a “governance,” “regulation,” or “management” of suffering populations. I pursue this end by focusing on what Karl Marx calls the “labor process.” Among other things, this means accounting for the vertically and horizontally structured social relations that paramedics and EMTs enter into while at work, including their relations with managers, patients, nurses, police officers, and more.
I argue that ambulance crews govern urban suffering by bandaging, sorting, and hustling bodies.
Paramedics and EMTs bandage bodies by offering superficial solutions to the suffering produced and exacerbated by capitalism, white supremacy, and other injurious systems. This can be seen not only when crews apply gauze and pressure to a bloody gunshot wound but also when they connect drugless patients to prescription-writing physicians or when they scoop a body from the cold sidewalk and move it into a relatively warm hospital bed. Ambulance crews are deployed very far downstream in a long causal river linking macrostructural conditions to personal hardship.
These workers ultimately constitute a reactionary force for stabilizing, but not fundamentally solving, many of the crises that disproportionately plague oppressed and marginalized populations. And, much to their frustration, most calls are not for the “legit” medical emergencies that they want to work. Most are for technically easier, but more frustrating, “bullshit” problems that ambulance crews are simply ill-equipped to handle. To be clear, paramedics and EMTs respond to a significant number of so-called legitimate medical 911 calls, and they mostly do so in disadvantaged neighborhoods. However, they are more typically rushing into these areas to respond to problems that are generally mismatched with the interventions that ambulance workers can provide.
Either way, much of their job means applying “Band-Aid solutions” to a variety of problems.
Ambulance crews also sort bodies and they do so through their regular interactions with nurses and cops. From determining whether someone goes to jail or the hospital to the specific emergency department a patient is transported to and at what triage level, these frontline workers shape how suffering populations are sorted across a number of spaces. Of course, these interactions are structured by inter- and intra- organizational protocols covering diagnosis, intervention, and more. But while protocols are important, they are often meaningless without labor on the ground to interpret and execute them. Paramedics, EMTs, nurses, and cops exercise significant discretion in determining how their subjects are sorted.
There’s a lot that influences discretionary action, but an interest to avoid so-called bullshit work seems to be a prominent motivation. As I detail in a chapter titled “Burden Shuffling,” these various frontline workers find creative and sneaky ways to push vocationally unfulfilling tasks onto others. For example, I document incidents where police officers shuffle unwanted cases onto ambulance crews by writing loosely-justified involuntary psychiatric holds and even by threatening to jail individuals who do not consent to an ambulance ride. I also recorded incidents where ambulance crews strongly recommended specific hospitals to patients because they believed such transports would help slow their shift down.
The details are complicated, but ambulance crews are not just bandaging bodies in the backs of ambulances. They’re also sorting bodies through their interactions with nurses and cops.
Finally, ambulance crews hustle bodies. My book illustrates how economic and political forces pressure paramedics and EMTs to complete as many billable transports as possible. The studied ambulance company holds a contract with the county government to deploy timely ambulances to anyone who requests them, and the county fines the company for late responses. In exchange, the company is permitted to run on a fee-for-service (or rather a debt-for-service) revenue model as an exclusive ambulance provider in the area.
Such conditions encourage managers to oversee a workforce that minimizes waste and maximizes efficiency. Their goal is to deploy a “lean fleet,” one that includes enough ambulances to avoid late response fines but not so many that labor costs begin to chip away at profitability. Unsurprisingly, managers want a busy ambulance fleet that hustles through billable transports. That might be good for capital, but it’s bad for workers and patients. For one thing, it produces incredible exhaustion for ambulance crews. As an EMT, I rarely received meal breaks during my 12-hour shifts and my employer did not provide ambulance stations for me to rest at between transports. They simply wanted me running calls. And this says nothing about ambulance wages being so low that many of my coworkers felt pressured to work over 50 hours a week. I know first-hand how the corresponding exhaustion can fuel tense interactions with patients, nurses, and cops on the front lines.
While ambulance crews may be bandaging and sorting bodies, they are often doing so in a hustled manner under the conditions of for-profit medicine.
THE GOVERNANCE OF URBAN SUFFERING
Here’s a sobering truth: we can continue to expect bodies toward the bottom of the urban hierarchy to disproportionately leak, gasp, scream, quiver, ache, and starve. Barring the emergence of a truly classless and antiracist society, the state will continue to govern the downward distribution of suffering, be it by aiding, punishing, or neglecting those who carry the brunt of hardship. The question is not will suffering populations be governed, but how they will be governed.
I hope Bandage, Sort, and Hustle can help us answer that question.
I also hope the book can provide concrete insights for change. I end the monograph with three recommended transformations that would improve ambulance operations for both patients and workers. First, we should decommodify (and not just deprivatize) ambulance services by replacing “fee-for-service” models with tax-funded revenue streams. This would reduce inequitable burdens for patients and attenuate the exploitation of ambulance labor. Second, we should expand the scope of ambulance interventions to better match needs on the ground. The ambulance could promote equity in the suffering city by linking people not only to emergency departments, but also to shelter, food, and other resources. This could also make ambulance work more meaningful for crews as they mostly have an authentic desire to help their patients. Finally, I encourage advocates of paramedical reform to join broader efforts to promote a more generous and equitable safety net beyond the ambulance. Scholarship on the “fundamental causes” of illness and injury suggest that things like a universal basic income, Medicare for All (or at least expanded Medicaid), housing-first programming, harm reduction policies, and more could reduce ambulance demand and better target the root sources of urban suffering.
That said, none of these changes would eliminate the need for ambulances. Just as we can expect suffering populations to be governed in some way or another, we can expect ambulance crews to be involved in that governance for the foreseeable future. We would be wise to pay attention to the important, yet complicated, work of paramedics and EMTs.