Opioids, Observation, and Restricting Access in the Public Emergency Room

This chapter presents ethnographic evidence of the restriction of medicine in the large, urban public emergency room. There are two routine problems facing triage staff: that there are always too many urgently sick patients whom staff have no real reason to favor for scarce hospital beds, and far too many less-urgently sick patients who technically should never receive beds. The rational rules of triage do not provide the means to reconcile these two problems and, moreover, they mandate that all of these patients be treated. The chapter details how a culture of understanding patients through criminal stigma, the widespread administration of pharmaceutical drugs during the wait, and police presence all work the resolve these two fundamental problems of hospitalization. It is this work that triage staff do—to produce patients that appear less medically needy—that ensures the extreme waiting lines do not become legally problematic.

The Medicalization of the Los Angeles County Jail System, 1978–2015

This chapter presents the historical transformation of the Los Angeles County jail system in order to explain why medicine has becomes a useful tool for jailers. Jails were successfully pressured into providing expanded healthcare by various legal agencies at the exact same time that they faced unprecedent budget constraint. In response, jails began thinking of their inmates less as violent gang members and more as mentally ill, substance abusers, and less threatening homeless persons. Doing so allowed them to draw in funding from other agencies and to release thousands of inmates. In total this resulted in the mere circulation of inmates between general housing and medicalized space as the key solution to the jail’s fiscal retrenchment and legal demands.

Conclusion

This chapter provides new language for thinking about public institutions and poverty governance at the turn of the twenty-first century. The goal is to think less about how criminal justice institutions are expanding, or public welfare institutions are downsizing, but instead to think about the disappearing of crisis. Administrative disappearing suggests in temporary resolutions of crisis certain kinds of social suffering are erased from the public record and transformed into more affordable kinds of social needs. This is an important move because unless we can center the reformulation of dying institutions amidst severe crisis, we miss shrouding specific forms of social suffering.

Building a Public Hospital That Everyone Knows Is Too Small

This chapter presents the historical transformation of the Los Angeles County hospital system in order to understand the restriction of medicine in large public hospitals. In contrast to a simple story of underfunding, the chapter details how legal demand and austerity pushed local government to reinvest in public healthcare but downsize inpatient capacity. Officials re-emphasized their patients less as local residents in need of urgent care and more as non-urgent patients, homeless, and immigrants in need of early intervention. Doing so allowed them to draw in funds from the federal government to reconfigure their healthcare systems away from inpatient care. In the process, however, legal and regulatory agencies began threatening public hospitals for dangerous overcrowding. Such pressure led directly to the development of waiting line management techniques—such as policing, closer observation of waiting patients, and opiate medication—that, in practice, worked to restrict care.

Summoning the Sick and Violent to Jail

This chapter presents ethnographic evidence to understand how medicine relates to the daily problems of filling up a large urban jail. The major problem of jailing is that there are far too many sick incarcerated persons and persons with serious criminal biographies than there are available specialized cells. The chapter shows that in order to resolve these problems, jailers reinterpret inmates’ biographies through stigma about the potential abuse of medical services and the widespread use of pharmaceuticals to quell disturbances. It is this work that jailers do, producing sick inmates, rather than the biographies that inmates bring with them, which ensures that the limited space of the jail can always accommodate the demand for space. In total, the expansion of medicine in jails is neither about serving inmates’ needs nor ignoring them, but instead is about using medicalization to resolve the fundamental problems of the overcrowded jail.

Introduction

This chapter engages existing myths about the transformation of hospitals and jails in urban America and offers an alternative theory. First, it engages the explanation of “deinstitutionalization,” which holds that the mentally ill occupy the jails because of state hospital closures. Second, it offers counter-evidence that public hospitals are restricting access to medicine because states have underinvested in them. Finally, it counters the idea of mass imprisonment, in which the overinvestment in criminal justice systems would explain the use of medicine to socially control the urban poor. In light of these explanations, this chapter introduces the reader to the new evidence of the book and an alternative theory of redistributing the poor.