This article explores the reductive workings of policy that lead to intimate everyday forms of violence within US-based medical administration. Using the framework of folklore of operational banality (“FOOB”), the article examines a geodata-driven way of addressing uncompensated medical care that targets “superusers” of the US health care system. The case scrutinizes the operative truths, procedural rationalities, and absurd reductions performed by this administrative system that sorts people in terms of cost and risk. It shows how such administrative strategies result in further bureaucratized inequities and harm, even as they claim to support life by ontologizing cost efficiency and cost-benefit thinking, accumulating biological data for geosurveillance and biosecurity, and treating risk and vulnerability as the property and responsibility of certain individuals/bodies and spaces rather than as the result of social-environmental problems. A parodic counterfigure appears in the case to amplify criticism of the individualized management of life/risk and the reliance on technocratic methods and biomedical models to define and allocate health care as separate from environmental and justice-oriented concerns. The figure of Health Coach App renders absurd the power relations of health interventions that exclude broader social etiologies of disease and illness and shows that collaborative approaches between environmental and medical humanities are needed to reveal banal administrative violence and to advocate for better policies.
Folklore of Operational Banality
We live in an age of administrative banality. Banal forms of power permeate our lives, often in ways we don’t even question yet with effects that are anything but quotidian. Banality—typically associated with the ordinary, commonplace, boring, dull, taken-for-granted—can also be understood as a governing affect. Examining banality as a means/mode of governance interrelates institutional performances and procedures with subjectivities and everyday practices. The term “operational banality” refers to the administration of institutions and management of daily life.1 “Operational” points to the how—how something is operative, procedural, and affected—while “banality” characterizes not only the “how” but also the “why” and the expected response. The messy and ambiguous terrain of banal norms, narratives, and their techno-procedural implementations comprises what I term the “folklore of operational banality,” or FOOB. Both as a popular concept and as an academic discipline, folklore focuses on the changing expressions of historical, communal, and environmental consciousness in the mundane processes of life and the political implications of those expressions. The folklore of operational banality concentrates on the broader, less human-centered category of administration. FOOB proposes to think orthogonally and relationally about bureaucracy in terms of banal protocols and managerial decisions mediated by algorithmic thinking and cost-benefit analysis. The framework of FOOB directs attention to the ways that narrative, presentation, and affect explain and support certain administrative logics and procedures as the most rational—and, therefore, ordinary—response, consequently perpetuating the operation because it is expected and unremarkable.
A system that demonstrates FOOB is reductive, tautological, and iterative—that is, incentivized to prioritize/optimize perpetuating itself. FOOB shows that once a “problem” or “problem population” has been identified and determined, this diagnosis mobilizes stories, affect, and procedures to administer the problem. These operations are relentlessly optimized and/or moralized and take on a life of their own, in ways that are simultaneously unremarkable/banal and absurd/grotesque. These qualities all require that FOOB systems demonstrate affect—of objectivity, passivity, disinterestedness (or sometimes caring, empathy, outrage, etc.) These are built into the folklore/narrative. The ordinary appearance of a FOOB system is therefore contrived. “Banality” describes not its ubiquitousness (though it may be ubiquitous), nor its regularity of occurrence (though it may be constant), but rather its affect. FOOB phenomena are characterized by an “affect plateau”: everything is presented with the same affect or through the same channel, making it difficult to differentiate levels of degree. For instance, an impending heat wave occupies the same register as threat of war. In the United States, the unrelenting post-9/11 orange-level security warnings and President Trump’s tweets (wherein all is hyperbole or outrage) lead to a “plateau of the extreme” that results in “horror fatigue.” The absurdity of the extreme is obscured by the affect of its presentation and the surrounding policy narrative.2 This banality of the exception is part of the reductive character of FOOB and leads directly to the “administrative grotesque”3: there can be no policy response outside the narrative; the possible choices have already been reduced to absurdity; the operational structures surrounding the choices are disincentivized to solve the problem or conceive of it differently; and the affect plateau prevents easy differentiation between the absurd and the quotidian. Therefore, the norms and administrative procedures surrounding the problem become fantastic, irrational, and ridiculous. And in many cases, they have negative effects—supporting injurious stereotypes and actions, rationalizing violence and racist imaginaries, exacerbating inequities—regardless of what the policy narrative claims to address or achieve. Tracking the banal organization of violence through everyday forms of regulatory decision and determinism that impact ordinary realities, FOOB reveals the empirical brutal absurdities of seemingly mundane administration.
Health is a primary arena of operational banality that involves “a mixture of banal doings (regimented, invasive, everyday, often quiet, violent, and normalized) with the phantasmatic (arbitrary and efficacious) imaginative geographies of class, gender, racial difference, health/sickness, and so on.”4 FOOB can be seen clearly at work in myriad medical administration programs and practices beyond the clinic or hospital. Following the twentieth century’s broad biomedicalization of the social landscape, almost anything can now be cast as a biomedical opportunity to intimately govern everyday life.5 Biomedicalization marks a shift in US medical administration. Due to the general expansion of statistical techniques and the availability and amount of data, biomedical policy folklore increasingly focuses on risk and surveillance in relation to molecular and genetic understandings of the body and “life.” This encourages the individualized management of life and risk, and normalizes—to the point of boring exception—reliance on technocratic methods to define and allocate health care provisions. Bodies and subjects are constituted through risk calculations and remedial interventions to enhance health—but also to advance new administrative structures, biofinancial opportunities, and medical intelligence gathering in the pursuit of biosecurity and defense.6
In the ever-expanding arena of health, FOOB administrative responses to identified problems reduce complexity to quantitative expressions to tell predetermined stories and/or perform simplistic heuristics. The biomedical model of the body contributes to this reductivist framing of health: it enables the body to be disaggregated into units of data, while space and context are reduced to irrelevance.7 The biomedical model works to contain breaches between body and environment by promoting the idea of the human body as a container of health; the onus is on the individual to manage bodily vulnerability and to reveal evidence of the body’s permeability. Spurred by liberalism, biomedicine individuates uneven health disparities through biologizing disease at the level of the body and categorizing certain populations and spaces as threats to health. Catherine Bliss explains that “largely genetic and geosurveillant approaches to social disparities have become rooted in the administrative bodies of the American public health apparatus.”8 This has led to increasingly militarized boundaries between body and environment, intensified surveillance at the level of the individual and population, and the expansion of militant subjectivities and biosocialities about health.9
Moreover, the biomedical construction of truth as located in the body facilitates an affect of disinterestedness, further rationalizing the collection of data to a self-perpetuating logic. Through systemic processes of absurd reduction and procedures that obfuscate their purpose, such biocratic grotesquerie supports the fiction that objective science and data processing are adjudicating the problem. FOOB normalizes exception: it administers a self-perpetuating feedback loop of data collection and accounting that can subsume, at the institutional level, efforts to redress racial, gender, and other social inequalities that cause/contribute to ill-health, disease, and death.10 Exception becomes the responsibility and property of those populations that are at risk and more vulnerable. Following decades-long rejection of social welfare, national and personal health administration in the United States regularly exhorts those most vulnerable to ill-health to take up their own structurally/environmentally disadvantaged positions as a project of self-care, resourcefulness, and responsible citizenship. Such policies can exacerbate or even replicate the health problems they are intended to resolve.11 Such dubious solutions depoliticize health issues, limiting responses to statistical accounting and individualized ethics undergirded by social bias.
Dominant US biomedical policy storylines routinize technical accounting procedures and data analysis, recursively justifying administration through moralizations about fiscal and physical health.12 Computer modeling and doctrinaire operations reiterate assumptions about self-vigilance and “deservedness.” Proceduralism at the biomedical institutional level and related forms of calculus and discipline at the individual level work to rationalize unequal outcomes of health and livelihood. For example, the operational banality of cost control, as a policy narrative, allows for spending the least while generating new obligations and structures to distribute resources. Market-based or genetic-based determinism perpetuates and rationalizes social inequalities: “risk” and “value” are attached to certain bodies and places as tautological path-dependent properties that require projects of self-discipline, prevention, and/or preemption. Against broader social etiologies of disease, medical administration sorts people according to cost, risk, and threat; it targets “problem” populations/communities and encourages social identification with new biomedical categories (genetic, economic, etc.) based on quantitative data. Technocratic proceduralism converts liberal modes of selectively affirming into complex/nuanced methods of exclusion based in abstract quantified protocols that appear to be neutral, objective, and ethical.13 Ultimately FOOB-based medical administration is not eradicating/solving the problem, but relentlessly monitoring and recursively indemnifying the status quo.
The remainder of this paper examines the everyday violence of health administration through a case study of medical hotspotting: its tautological targeting and surveillance of racialized superusers of the US health care system.14 The empirical discussion features a counterfolkloric figure, inspired by creative folkloric interventions in dominant discourses of ecological crisis and their technical-managerial solutions.15 The inclusion of this figurehead serves to challenge the “biocratic grotesque” through critical writing and counteraesthetics, and to create openings to imagine policy alternatives by using theatrical techniques of humor and spatial disorientation. Health Coach App displays community-based environmental justice concerns in surreal juxtaposition with medical hotspotting’s reliance on geosurveillance and individual health data monitoring as the method of coordinated care.16 Using techniques of parody and irony, Health Coach amplifies the absurdity of the policy arena’s operational banality—the ridiculous policy storylines, administrative procedures, knowledge production, and affect.17 It seeks to subvert the individualizing of health and prioritizing of immunity, purity, and technical solutions tied to biosecurity demands. Such notions have too often depoliticized health injustice.
A concluding “reflections” section draws together the implications of FOOB for environmental health and health justice. I argue that FOOB offers a way to show that the exception should not be the norm, by magnifying and scrutinizing the everyday violences of the “affect plateau,” whether that be the banality of clinical and scientific reductivism, tautological statistical models, tyrannical probabilities, militant environment/body divisions, or racialized disciplining of spaces and the experience of disease. The approach asserts the important role of folklore and environmental humanities in response to biomedical rationalities and their simultaneously banal and brutal realities, particularly to contest the boundaries of the human body and nonhuman environment, the modern construction of the body as a discrete and bounded entity, and the isolation of medical from environmental and technological concerns.18 FOOB forces such boundaries to become more visible, to make openings for more relational, embodied, and environmental understandings of health.
Medical Hotspotting with Health Coach App
A prevailing policy narrative appears to address health as a social issue and to alleviate health disparities.19 Medical hotspotting is “a problem-solving technique that targets the most expensive problems and/or in-need people by allocating resources to specific problem areas as revealed by the data.”20 Medical hotspotting mobilizes medical data, GIS technologies, and predictive policing strategies to determine risky people and problem spaces on a map of health care cost. The idea is to reroute health care dollars and resources toward underserved areas, to prevent their drag on the health care system.21 However, targeting the “superusers” of health care foments racial enmity and may further intensify the risks of non-White life and being poor in the United States under the auspices of improved health intervention and coordinated care.22 Medical hotspotting advances surveillance at the level of the population for the purposes of biosecurity, by predicting and deterring threats—the “hot spots” of excessive users of the health care system. The operation then customizes the intervention by sending in an interdisciplinary team of caregivers that largely focus on changing the behaviors and choices of the high-risk individual. Even as broader social-structural issues are acknowledged, the onus is placed on personal responsibility. The biomedical model of the body in health care fails to address environmental health inequities—a tragic oversight in the context of Camden, the birthplace of medical hotspotting, where large-scale waste processing has served as the means to “reverse” industrial decline.
The practice of medical hotspotting began in Camden, New Jersey, an industrial city across the Delaware River from Philadelphia. Following the collapse of its manufacturing base and decades of White flight and disinvestment, Camden became a container of poverty within a deeply racialized region.23 Currently it is considered to be one of the most blighted areas of the northeastern United States, with a population of approximately seventy-seven thousand that is per capita one of the poorest in the nation. Camden residents confront the everyday environmental onslaught of the city’s hosting a regional sewage treatment plant, an open air sewage sludge composting facility, trash-to-steam incinerator, power-cogeneration facility, petroleum coke transfer station, machine shops, chemical companies, cement-grinding plants, junkyards, food processing plants, among others.24 The presence of toxic industries, combined with poverty and violent crime, all have contributed to a dire public health problem in Camden, where the city’s residents are majority Black and/or Latinx.25 Medical hotspotting emerged in this industrial-racial geography as a means to decrease exorbitant health care spending on the medically indigent by coordinating a data-based approach to intensive outpatient care for complex high-needs patients. The methodology and program are attributed to Dr. Jeffrey Brenner, whose personal and professional interest in addressing violence in Camden led him to obtain and coordinate data from Camden-area hospitals.26 Armed with this metadata, Brenner mapped Camden’s medical information: one percent of patients were driving thirty percent of medical costs, and a single public housing development was alone responsible for $12 million in health care costs from 2002 to 2008.27 People with the highest medical costs and the greatest number of emergency room visits were usually receiving the worst care and were, reportedly, making “detrimental lifestyle choices.”28
Medical hotspotting endeavors to reorganize health governance according to the economic logic of cost efficiency and statistically determined social disparity—but without engaging the city’s political-economic and industrial-ecological context. Its administrative folklore ties public health to public safety by expanding the medical gaze beyond the spatially limited, crisis-event orientation of hospital care. While this could be promising as a way to “see” social problems, such as housing, beyond a strictly biomedical focus on the human body, medical hotspotting ultimately contains the social-spatial intervention to that of medicalizing and altering behavior and fostering wellness under the purview of public-private partnership philanthropy. Medical hotspotting supports a form of biological citizenship dependent on a mounting nonprofit philanthropic complex that delineates high-risk people with multiple vulnerabilities for the purposes of motivating them to do better self-care and cost the system less. This complex justifies its expansion via the “manifest destiny” of data collection and administrative goal of perfecting “seeing like a budget.”29
Medical hotspotting has gained traction, from Trenton and Scranton to Denver, Las Vegas, and Anchorage, as a way to facilitate preemptive care and cut down the number of medical crises requiring expensive hospitalization and treatments.30 In addition to using sophisticated data mapping to direct more efficient and effective care toward concentrated zones of high utilizers, medical hotspotting enlists interdisciplinary team work and house calls to restructure the organization and delivery of health care. Care management under medical hotspotting aims to create “authentic healing relationships” during nine to twelve months of one-on-one with each patient, following hospital admittance and qualification into the program.31 Care teams apply an instrument called COACH that seeks to build “patients’ self-efficacy” and a nuanced emotional relationship between patients and care team providers to drive active individual health management.32 The Camden Coalition of Healthcare Providers further explains, “We work with each individual to create a customized care plan, centered on their own goals and wishes, that helps them realize their highest level of health and well-being.”33 COACH offers a client-centered evidence-based method that uses empathy, motivational interviewing, and open-ended questions to inspire behavioral change.34 Teams train patients in healthy choices that will enable them to maintain their own care and stay out of the hospital. This might entail wellness promotion and psychosocial counseling, helping patients apply for government assistance programs, securing better housing or temporary shelter, and adapting to home life after hospital discharge.35 A promising aspect of medical hotspotting, then, is to stabilize both the medical conditions and social environment of patients as a means to health.
Medical hotspotting branches out care interventions to enlist social services beyond the hospital and formal biomedical arena. Care plans often seek the support of longer-term care networks of family and friends.36 However, care relations remain mediated by the quantitative data (biomedical and beyond) and overall cost efficiency logic that justifies the health intervention. The asymmetrical power relationship of “intervention” considers the data to be the authoritative means/grounds of a place’s intelligibility, thus depoliticizing knowledge production to that of technical accounting. This is perversely evident in medical hotspotting’s Camden origins. In spite of decades of social justice activism, particularly in response to the area’s pervasive industrial contamination and inequitable clustering of waste industries, the scholarly studies of medical hotspotting by Camden practitioners thus far do not address environmental health issues, especially the subjection of residents to chemicals, diseases, and risks. Medical hotspotting’s folklore “lets the data speak” to justify geosurveillance and care coordination but not to tell the story of truancy hot spots linked to lead-poisoned waters in schools or spectacularly elevated rates of emergency room visits for asthma flare-ups by residents subjected daily to sewage treatment facilities, incinerators, and cement truck traffic.37 Evidently medical hotspotting’s efficacy as a model of care coordination necessitates divorcing the human body and health from the environmental conditions, political economy, and existing community activism present in its application context.
The counter-FOOB figure “Health Coach App” (see figs. 1–5) suggests that medical hotspotting, by installing technical procedures and institutional sorting mechanisms that define who deserves care, may ultimately serve to medically redline people, ration resources, and obscure environmental considerations in relation to health. Uniquely positioned at the interface of the public/private and individual/institutional, Health Coach references in-person health coach services and a technical-wearable device sent into the field to monitor and encourage behavioral changes in the conduct of patients.38 Unencumbered from reporting on the intentionality of medical hotspotting practitioners, the fictional app questions the surveillance functions of the practice, and the ethics of its coaching affect. It reveals the absurdity of advocating for individualized healthy choices, when no change has occurred in the US social production of poverty and vulnerability. The screen interface mimics the self-motivational discourse and behavioral monitoring of technology “wearables” like the Fitbit, to lampoon the affective disciplining performed by the aforementioned COACH protocol. Health Coach also interjects—through deadpan juxtaposition—a live feed of accounts of Camden’s environmental harms, statistics on discrimination, and confrontational quotations from ordinary resident-activists.39 Such local information conveyed through screenshots contradicts the evidentiary basis of medical hotspotting’s community orientation, and it renders the efficacy of entrepreneurial self-care ridiculous within the political economy of Camden’s waste and medical complex.40 Although the app is fictitious, the author intends for the interface to serve as a critical spatial and community-based guide to Camden city—to be used on-site or as a multimedia “countermap” of Camden.41 Below, Health Coach screenshots accompany and annotate further discussion of the potential implications of medical hotspotting, as its pace of adoption quickens across US medical administration.
In the context of austerity policies and widespread concern about the overtaxed US health care system, medical hotspotting hews to the logic of cost efficiency concerning health care dollars. In doing so, it promotes a racist national imagination of those who are worthy of scarce resources: an imagined community of deserving (White, suburban, healthy) American families set against the undeserving, leeching “high utilizers” and “high risk” populations, categories that serve as proxy for racialized others. High utilizer has joined “welfare queen” and “gangbanger” in the pantheon of demonized subjects that endanger the US national health care budget and the health of so-called worthy citizens.42 The call to locate the superuser one percent marshals racism through the powerful rhetoric of statistics and fairness. There are countless examples of this circulating in the media, such as, “there’s a small segment that is burning through 20 percent of our society’s wealth at a massive rate.”43 This language and statistical operation facilitate the transfer of blame and placement of responsibility on those who are already disadvantaged, by locating the small segments of uninsured or under-insured people that are allegedly “burning through society’s wealth.”44 The superuser is identified through hot spot delineation, where inhabitants-as-threat inhabit the space-as-threat, and vice versa. Health Coach interrupts this racist imaginary by channeling evidence of cityspace as anything but a neutral backdrop. For example, the app juxtaposes the affirmation “you are in control of your lifestyle” with statistics that show the enormous disparity in housing loans along the color line within Camden and the massive disparity between rates of home ownership in Camden compared to the national average (fig. 1).
Health Coach suggests that medical hotspotting promotes self-care in the absence of social welfare.45 While autonomy and empowerment to make oneself healthy are laudable goals, this relegates the fact that people exist within uneven economic, social, and environmental conditions to a matter of the private and personal sphere—to a matter of choice about how to live a healthier lifestyle and adjust one’s behavior in line with normative models of health. The app interface (fig. 2) applauds the viewer with the observation “you choose to exercise regularly,” yet this praise of ordinary activity associated with good health is qualified by a declaration of grocery store scarcity and lack of access to food and nutrition faced by Camden residents. Even as medical hotspotting attempts to cultivate social infrastructure and stability through caregiving, such efforts are undermined by a behaviorist emphasis that ignores the structural conditions of poverty and even blurs welfare and penal policies. Medical hotspotting intervenes in the daily care of categories of patients, such as the mentally ill, medically fragile elderly, and the “socially disintegrated,” that is, “those who tend not to engage in self-care, have few family resources and display dependent personalities.”46 The sorting out of the so-called “socially disintegrated”—those who fail at/to self-care—from “productive citizens” allows for race and poverty to be understood as markers of risky and dysfunctional social behaviors, rather than as structural positions that increase vulnerability.47 It also signals a shift in health governance toward aggressive programs of moralizing behavioral workfare that mandate personal responsibility, while the state withdraws institutional supports for illness and unemployment.
Part of the larger political economy of geospatial data, medical hotspotting depends on the mass collecting of medical data. In the most general sense, metadata aggregations scale up and interrelate different data sets, providing more material to enhance our understanding of the larger social and environmental genesis of health problems. Yet with medical hotspotting, the imperative to find high utilizers of the health care system entails a self-fulfilling process of data analysis: the sick and disenfranchised are always the population, never the control group, and those who are healthy among the population are statistically illegible. This medical intelligence represents an intensification of the division of labor of managing the poor and industrial remains.48 It orchestrates a kind of “data colonialism” that extracts value by quantifying and surveilling marginalized people, and facilitating the infiltration of big data into the banality of everyday life.49 Medical hotspotting avouches objective truth—that geodemographic information processing is somehow neutral. In doing so, it obscures how algorithmic processes of selection, analysis, and sorting tell stories and create meaning that advance market orientation and naturalize the inequities of capitalist growth. One screenshot (fig. 3) shows Health Coach App exhorting the user that “everyday you are getting better,” which emphasizes self-responsibility for pulling oneself out of poor health and poverty. The location icon underneath, however, draws in a quote from community activist Father Michael Doyle of Camden’s Sacred Heart Church, who locates the neglect of Camden’s poor within an actively abusive uneven geography with the suburbs: “You’ve got your foot on our neck. That’s why we can’t stand up.” The quote refuses the depiction of Camden as an isolated postindustrial enclave of poverty and provocatively depicts the active making of the region’s racially disparate capitalist growth and decline, thus protesting its deadly effects.
Medical hotspotting involves spatial profiling that ultimately risks normalizing—spatially ontologizing—historical geographies of racial domination (urban renewal, race-based zoning/redlining in housing and mortgage industries, environmental racism) as simply geodemographic “facts” on a map.50 From crime mapping and policing, medical hotspotting borrowed technologies, such as CompStat, that collect and use spatial data to model, monitor, and control criminal behaviors. First instituted by then New York City Police Commissioner William Bratton in the mid-1990s, “crime hotspotting” generates digital cartographic representations of high-crime areas by linking statistical information, such as crime type and occurrence, with zip code and neighborhood.51 By mapping this racially stratified datascape of expectations, police anticipate and target high-crime spaces by customizing surveillance (rather than use blanket police enforcement). The medical application of crime hotspotting integrates GIS data and demographic techniques that similarly assert: Where you are reveals who you are.52 Racialized spaces and bodies become ontologized as measurable, knowable geotags and data of a population that can be targeted—even though medical hotspotting does not explicitly involve racial profiling. Health Coach App questions the narrative of Camden entrenched by such statistical mapping (fig. 4). While the upper-level display places the onus on the individual to “seek the help you need,” the lower-tier window showcases a quote from a Camden native that contests the unfair burden of pervasive racial and spatial profiling of the city and its residents. Emphasizing her educational background and success in business, the speaker explains that she grew up in Camden and is concerned about its toxic environment, but her life as a person of color living in the city cannot break out of the pernicious enclosure and devaluation of the place and population.
Medical hotspotting mobilizes what Jenna Loyd has called “slum reasoning” as a preemptive way of seeing, of knowing-as-containing.53 Further entrenching social borders and spatial segregations, medical hotspotting allows for/rationalizes racially segmented care: an intensified form of medical redlining that potentially rations medical resources and health care—a perverse reversal of the common practice of overprescribing to the poor.54 Part of the legacy of militarized visual culture, such targeting dramatically translates military dreams of high-tech omniscience into the governance of urban civil society.55 Geosurveillance in the case of medical hotspotting secures target fields of information and spatial data about high-risk people and spaces for the purposes of biosecurity—that is, managing health for the optimization of the population by tracking/mapping those bodies and spaces against which society must be defended.56 The geosurveillance technologies of medical hotspotting proceed from a militarized interpretation of residents as risk factors that need to be logged, understood in a calculative statistical manner, mapped, modified, and controlled. As a result, medical hotspotting administers disease prevention and health promotion as a form of intensified and increasingly militarized preemption; it entails a political rationality that calls forth surveillant uses of technology and transforms governing into a field of perception.57
Following an initial spate of articles that extolled medical hotspotting’s innovative use of police technologies—with one headline declaring “when treating patients like criminals makes sense”—medical hotspotting now promises to expand and integrate data from numerous institutions and social services, including hospitals, jails, and schools. The project “Camden ARISE”—“administrative records integrated for service excellence”—endeavors to track people across medical, behavioral health, criminal justice, education, and housing sectors; this will enable administrators to locate cross-sector superusers and figure out ways to preemptively intervene to contain the costs of not only emergency room visits but also truancy and recidivism in the criminal justice system.58 Such data-sharing partnerships and collaborative interventions accept current conditions of fiscal austerity and reinforce the dominance of nonprofits/private philanthropy in government service operations. It raises important questions about privacy and the rights of citizens and residents in “poverty hot spots”: those who rely on social services may now be categorized and further stigmatized as multisector “repeat offenders” in the absence of public provisions and responsibility. Such integrated surveillance justifies and perpetuates itself in terms of administrative waste elimination and cost reduction without reference to the actual health conditions of Camden, where a declining tax base, high unemployment, and widespread environmental hazards attenuate quality of life. A final screenshot (fig. 5) suggests an alternative way of assembling facts and policy narrative around Camden residents. Here, Health Coach rebukes the displayed affirmation “you are stronger than any excuse” and its praise of individual responsibility. The app instead assembles an alternative set of statistics that link public schools in Camden to bad air pollution and thus to high asthma rates and disproportionate emergency room visits by city residents. The idea is to make statistical associations that begin to tell a story about how Camden children may incur high truancy rates because of environment-related health problems.
The preceding case demonstrates the banal violences of health administration. We see how biomedical programs and operations abstract biological data from individuals in their ordinary contexts; normalize the reliance on technocratic methods to define and administer health care provisions and reduce costs; and exclude broader social-environmental etiologies of disease to focus on the individual body, behavior, and spaces. “Objective” neutral technical problem-solving dominates this biomedical policy folklore. Technocratic proceduralism in the health arena connects with liberalism’s prioritizing of the individual as political actor/legal unit and biomedical understandings of the body as a discrete container of health. This conjuncture works to narrow health problems to that of humans/human bodies while also effectively dehumanizing the response—by despatializing and dehistoricizing the body and invisibilizing inequities. This allows institutionalized policy approaches to health to individualize illness and disease as a project of self-vigilant care and/or objectifying blame, and focus on behavior, risk, surveillance, and biosecurity, to the exclusion of “transgenerational health effects, institutionalized forms of discrimination, and social environments.”59
We saw FOOB at work as a framework for analyzing policy folklore and the complex administrative systems that come to govern people’s livelihoods and bodies. The affect plateau names a situation wherein the absurd and quotidian cannot be differentiated, because norms and procedures surrounding the problem to be solved have become reductive and ridiculous and acceptable/taken-for-granted as the only response within the policy narrative. Moreover, the operational structures surrounding policy storylines and responses are disincentivized to solve the problem or conceive it differently. The administrative/biocratic grotesque refers to the normalizing and optimizing of the “problem subject’s” deficient status—in other words, that calls on individuals to take on responsibility for their own structurally disadvantaged positions—and the obfuscating function (the not solving) of policy interventions and technical procedures that regularize death, injury, and inequity. Certain populations are cast out and/or targeted for monitoring and intense disciplining—and this registers at the level of the body in harmful, deadly ways. The figure of Health Coach served to underscore the policy story and banal procedures that fold in edge cases and sort people in terms of high-cost and high-risk populations and bodies, obfuscating the life-death stakes, sacrificial effects, injuries, and forms of collateral damage that are made ordinary and participatory.
Basically, FOOB directs our attention to the banal forms of administrative violence and mundane organization of health inequities and lethality that make the exception boring. This boring exceptionalism allows reduction in scope as well as kind, by treating history/geography/environment as qualitative externalities. As the case study of medical hotspotting illustrated, medical administration relies on so-called objective data sets and neutral protocols that disregard ill-health and suffering as social-environmental processes and outcomes. Solutions focus on creating technocratic and often militarized boundaries between the problem population and society, body and environment, policy story and procedural implementation that maintain the status quo. Health Coach sought to disrupt the “common-senseness” of these procedures and rationalities that lead to the biocratic grotesque, across the terrain of institutions to the body and everyday life.
FOOB draws our attention to the ways the banality of such forms of administration lulls us into thinking we’re doing something; the banality of their operations makes it seem like we’re endlessly doing (locating the underserved, getting tested, etc.). But such policy efforts and procedures undo the possibility for change: political responsibility is relinquished under the guise of endlessly doing, while they mostly accomplish not doing—medical hotspotting does not actually tackle poverty or racist environments. Such not doing, as FOOB shows, can lead to everyday deaths and injuries that are normalized brutal realities. The forms of medical administration scrutinized by FOOB are iterative and tautological “doings” that fulfill their mandates ineffectively if at all. Their appeals to the authority of data and risk calculus deliver false promises. The programs give the appearance of fairness but obfuscate the stakes, costs, damages, and/or geographies of harm; their deadly effects are obscured through their banal participatory administering. The figure of Health Coach also shows how administering interventions and care can co-opt the storylines and policy affect of grassroots activism into value-generating obscurity—via a numbers-based “blankness” or simply by ignoring collective action.
Finally, FOOB endeavors to counteract the lethal/injurious banalities at work in health and biomedicine (that are ostensibly about enhancing/optimizing life). FOOB counterfolklore attempts to inspire people to design different kinds of systems and policies that aren’t subject to biocratic absurdities—that don’t lead to the rollout of technical procedures or the affect that looking for the extreme and incorporating more data points is the best/only way to think about the problem. Figures like Health Coach App are useful because they insist that to have better policy, one must rework the policy narrative and the power relations and procedures it establishes that are doctrinaire, diffuse rulemaking, fetishize data collection and risk assessment, and reduce the subject to a mere package of quantifiable data. Alternative policy storytelling must advocate for more widespread political discourse on defining problems, collecting data, and pursuing justice. For “what can and does get measured is not always worth measuring, may not be what we really want to know, and may draw effort away from the things we care about.”60 The case also suggests rethinking investments in US biomedical models of the body and liberal health rights approaches in the pursuit of social-environmental justice. Contra technical administrative procedures and affective disciplinary techniques to contain and normalize exception, FOOB counterfolklore accentuates the everyday lived permeable boundaries of the human body and environment—the absurdity of denying this reality—and the harmful embodied effects of any response that rejects these embodied interchanges and porosity. Such responses actually perpetuate the asymmetrical power structure of “intervention” that allows for ongoing conditions of ill health, subcitizenship, and premature death.61 FOOB prompts us to consider health interventions as folklore, to reconsider what’s at stake, and to imagine a more equitable collective politics of bodies, health, and the environment.
I am grateful for the insights of Dan Clayton, who invited me to give the 2015 Neil Smith Memorial Lecture at the University of St. Andrews, where I shared an early version of this project. Many thanks to Caren Kaplan and the 2018 Everyday Militarisms research collaboratory at the University of California, Davis, where I had an opportunity to revisit and advance these ideas. Collaborations with Nadine Ehlers, Greig Crysler, Sarah Kanouse, Kate Chandler, Javier Arbona, and Andrea Miller continue to inspire my experiments with creative scholarship. Finally, there would be no FOOB without Joshua McDonald.
This framework draws on Hannah Arendt’s foundational work on banality in Eichmann in Jerusalem and “Thinking and Moral Consideration.” Additional banality studies include, for example, Mbembe, “The Banality of Power”; Trouillot, “The Vulgarity of Power”; Foucault, “8 January 1975.” Feminist scholarship of banality and everyday militarism includes Christian, Dowler, and Cuomo, “Fear, Feminist Geopolitics, and the Hot and Banal”; Kaplan, “Precision Targets”; Katz, “Banal Terrorism.”
Michel Foucault (“8 January 1975”) characterizes the fantastic, irrational, often ridiculous nature of power operationalized through mundane bureaucratic functions as the “administrative grotesque.”
Dan Clayton (lecturer in geography and sustainable development, University of St. Andrews), email correspondence with the author, November 26, 2015.
Biomedicalization involves the increasingly technoscientific nature of biomedical practices and widespread privatization/corporatization of health care. See Clarke et al., Biomedicalization.
Biofinancialization refers to practices of investing in domains where life is valued, sorted, manufactured, and bought/sold—the reduction of life to funding problems and opportunities through economic thinking. A vast literature exists on the environment and risk. This article draws on a subset that explores environmental ethics/responsibilities in relation to risk and that challenges the way bioethics became a discipline of “medical ethics” divorced from earlier ecological concerns. See: Smith, Against Ecological Sovereignty, 135–58; Macnaghten, “Risk and the Environment”; Fiore, “Bioethics: Environmental”; Dwyer, “How to Connect Bioethics and Environmental Ethics.”
Nash, Inescapable Ecologies, 202. Biomedicine abandons the holistic approach to environmental health for a more ontological and reductive one that abstracts the environment into quantifiable factors (risks, pathogens, etc.) and focuses on the interior of the body.
“Biosociality” points to the ways individuals form social relationships and produce collective notions of identity based on shared genetic or biological conditions. See Rabinow, “Artificiality and Enlightenment.”
Jodi Melamed (“Proceduralism, Predisposing, Poesis”) refers to bureaucracy’s “will to institutionality”—a bureaucratic mode of production akin to FOOB.
Preston, “The Birth of Clinical Accounting.” This is part of a longer history, including structural shifts to microtransactions and genetics, predictive mechanisms and the fetish of data collection, modeling based on deficiencies, and actuarial science and risk monitoring with execution linked to microeconomics.
This case study is an extension of research conducted with Nadine Ehlers and featured in our 2019 coauthored book Deadly Biocultures.
See, for example, Thornton and Thornton, “The Mutable, the Mythical, and the Managerial.” The environmental-medical humanities approach here also draws on Annemarie Mol’s innovative The Body Multiple.
Health Coach App emerged as a figure during the author’s fieldwork at Northgate II tower, one of Camden, New Jersey’s, medical hot spots. The author met a parking lot monitor who excoriated efforts to police individual people rather than tear down the tower for making people sick (as a result of environmental hazards). The author subsequently worked on an interface design that would blend Fitbit affirmations with a guided “toxic tour” and environmental justice geography of Camden activism. Health Coach remains a speculative project and is thus not (yet) available for use.
The figure blends satire and sincerity and operates in proximity to that which it criticizes, in the spirit of mock institutions such as the National Toxic Land/Labor Conservation Service.
The Health Coach App project was initiated by the author following research conducted with coauthor Nadine Ehlers on the racial biopolitics of health: Krupar and Ehlers, “Biofutures”; Ehlers and Krupar, “‘When Treating Patients Like Criminals Makes Sense’”; Ehlers and Krupar, Deadly Biocultures, 47–68. Note that medical hotspotting’s efficacy has been called into question at the time of this article’s copyediting.
Pomar and Cole, “Camden, New Jersey, and the Struggle for Environmental Justice”; Sullivan, “The Most Toxic Sites.”
Sicotte, From Workshop to Waste Magnet, 148; also see US Census Bureau, “Camden City, New Jersey.”
Bush, “Health Care’s Costliest 1%”; Rentas et al., “Characteristics and Behavioral Health Needs of Patients,” 2.
For example, the Special Care Program in Seattle for Boeing workers, CareOregon’s geomapping nonprofit health plan, and Southcentral Foundation’s health care system in Anchorage, Alaska.
Grinberg et al., “The Core of Care Management,” 248–49; Martinez et al., “Time and Effort in Care Coordination for Patients.”
Environmental injustices experienced by South Camden waterfront residents took on national significance after their court case advanced to the US Supreme Court. See Jurand, “‘Environmental Justice’ Movement”; Pomar and Cole, “Camden, New Jersey, and the Struggle for Environmental Justice”; Cole and Farrell, “Structural Racism, Structural Pollution, and the Need for a New Paradigm”; New Jersey Department of Environmental Protection, Site Remediation Program, “Known Contaminated Sites of New Jersey Reports.”
Health Coach App references the former health coach program under medical hotspotting: AmeriCorps participants trained and served as health coaches on care teams until the termination of the AmeriCorps Community HealthCorps national program in 2016.
The Health Coach App messages about Camden are culled from several sources. Figure 1: Glantz and Martinez, “Kept Out,” and DATAUSA, “Camden, NJ”; Figure 2: Terruso, “Camden Gets a Supermarket”; Figure 3: Kirp, Dwyer, and Rosenthal, Our Town, 185; Figure 4: Milman, “Air Pollution”; New Jersey Department of Environmental Protection “Camden Waterfront South Air Toxics Pilot Project”; Figure 5: New Jersey Department of Health, Asthma Awareness and Education Program, “2014 Camden County Asthma Profile”; New Jersey Department of Health, “Camden County Public Health Profile Report: Asthma Incidence”; New Jersey Department of Health, “Camden County Public Health Profile Report: Asthma Hospitalizations.”
Camden has been pursuing an “eds and meds” approach to development with higher education and health care nonprofits as anchor institutions for the city’s “rebirth.” Camden is also a state-designated “growth zone” with major tax breaks. See Darling, “Eds and Meds Task Force”; Solomon and Pillets, “How Companies and Allies of One Powerful Democrat”; Crysler and Krupar, Waste Complex.
Countermapping generally refers to a mapmaking process, often community-based, that subverts official maps to render alternative experiences, rights, and spatial knowledge (Krupar, “Map Power and Map Methodologies”).
Doug Eby, MD, of the Southcentral Foundation health care system, quoted in Bush, “Health Care’s Costliest 1%.”
Roberts and Mahtani, “Neoliberalizing Race, Racing Neoliberalism”; Gilmore, “Fatal Couplings”; Ehlers and Krupar, “When Treating Patients Like Criminals Makes Sense.”
For an extended review of medical redlining, see Randall, “Institutional Racism.”
Crampton, “The Biopolitical Justification”; Kaplan, “Precision Targets,” 694–95; Foucault, “17 March 1976.”