Over time, providers who work with high utilizers are able to categorize patients into distinct groups . . . [one of which is described as] “socially disintegrated,” [those] who tend not to engage in self-care, have few family resources and display dependent personalities.
—Haydn Bush, “Health Care’s Costliest 1%”
The student must ignore . . . these extreme statements and seek to extract from a complicated mass of facts the tangible evidence of a social atmosphere surrounding Negroes, which differs from that surrounding most whites; of a different mental attitude, moral standard, and economic judgment shown toward Negroes than most other folk.
—W. E. B. Du Bois, The Philadelphia Negro
On August 1, 1896, W. E. B. Du Bois began a fifteen-month-long sociological study commissioned by the University of Pennsylvania, which was eventually published as The Philadelphia Negro: A Social Study (1899).1 Widely recognized as the first great empirical book on black life in American society, Du Bois’s study included an analysis of the health conditions of Philadelphia’s black population and might be seen as part of a race-specific biopolitics of health within the biocultural sphere. The biopolitics of health, in its most general sense, refers to the administration of health that manages and standardizes the life of the population—to make the “biological citizens” of the nation live more.2 What Du Bois makes clear in his study, however, is that the administration of the biological life of the population in the United States has been “cut” by racism and entrenched racial disparities.
Indeed, the first function of racism, Michel Foucault tells us, is “to fragment, to create caesuras within the biological continuum.”3 The “cut” of racism has meant that different segments of the population have been administered in distinct ways and, importantly, that white lives have been affirmed and made to live in ways that other lives have not. As Michael Dillon and Andrew W. Neal have argued, race functions as a marker that biopolitically adjudicates: race “does not only specify life’s eligibilities for this or that good—it ultimately specifies whether or not a life is to be considered eligible for life as such.”4 Viewed through this lens, the differential governing or management of black subjects—Du Bois’s focus—both often operates as a form of violence against the black body/subject and situates African Americans as separate from the wider population and the polis. Du Bois’s investigation highlights that the city of Philadelphia—by way of commissioning this work—sought to better manage and secure what were seen as the potentially dangerous problems of the African American population.5 It is in this way that the study operated as a race-specific biopolitics of health, wherein black life (and blackness itself) was articulated as an ontological problem (the infamous “Negro problem”) to be studied, measured, and ultimately contained.6 The political problem of black life was deemed the product of supposed inherent black difference—a difference that required regulation. Du Bois both refused and inverted this logic: reframing the so-called Negro problem in terms of environmental factors and relentless historical disenfranchisement, he showed that African American problems regarding health were “largely a matter of the condition of living.”7 Ultimately, Du Bois insisted that, as a problem produced through social conditions, black health—or lack thereof—needed to be attended to and normalized in line with the cultivation of white subjects. We might say, then, that the Du Boisian study was a demand that the “cut” in the biopolitical fostering of life—along the color line—be remedied through a more affirmative focus on black health. For Du Bois, however, this would be achieved not through a focus on blackness as a “problem” but through addressing the manifold social factors that thwart black life.
Biomedical Targeting of Race
Contemporary biomedical technologies that target race seem to ameliorate the “cut” of systemic racism—by targeting supposedly race-specific health factors or directing health care toward particular spaces to alleviate health disparities.8 We view these biomedical targeting technologies as part of broader biocultures of race-based health—an often-amorphous arena that encompasses efforts in (and relays between) the biological sciences, clinical medicine and public health, the pharmaceutical industry, and patient and community-based advocacy to address health and illness through the lens of race. In what follows, we consider two examples of biomedical targeting technologies and their biopolitical and disciplinary operations. First, we focus on BiDil, a pharmaceutical approved by the U.S. Food and Drug Administration (FDA) in 2005 and subsequently marketed as a race-specific drug for self-identified African Americans suffering from heart failure. Second, we turn to what is known as “medical hot-spotting,” a practice that began in Camden, New Jersey, in 2007 and that uses GIS technologies and spatial profiling to identify populations that are medically vulnerable (“health care’s costliest 1%”) to provide preemptive care at home and lower hospital admissions and health care costs. These targeting technologies—or operations—are deployed ostensibly to affirm life within biocultures of race-based health: they are said to redress past forms of biomedical neglect and enable the tailoring of biomedical intervention into vulnerable communities, and they are advocated as the means through which to foster the health of those populations—through attention, through targeting. Such forms of redress and attention might be understood, then, as the attempt to practice—and actualize—a different racial future, precisely through attending to inequities in the present.
However, targeted health interventions may in effect signal inequitable and endangering forms of biomedical administration.9 We advance this more cautionary view through three foundational claims. First, regardless of the motivations for biomedical targeting—that is, the will to attend to minority health—the operation of race-specific biomedical targeting is structured through dominant epistemologies of race that position nonwhites as Other to the normative Human. More than racist actions or the architecture of racial discrimination, this form of knowledge designates nonwhite subjects as the constitutive outside of the normative world. Not only has this dominant epistemology of race shaped the racial past in the United States but it also curtails the present and future of nonwhite life. Specifically in relation to black subjects—who live in a paradigm that binds blackness and death together—it is a form of knowledge that positions the black subject outside of the category Human.10 This positioning stems from liberal humanist thought and is constitutive of Western modernity.11 Such expulsion of black lives from the normative position Human is undeniable, “given the histories of slavery, colonialism, segregation, lynching,” and the ongoing daily imperiling of black lives through police brutality and mass incarceration.12 That biomedical targeting is structured through such epistemologies of race is evident in the way it reinstitutes racial difference and separation and, as we will show, stages an additional form of violence by actually expelling blacks from the possibility of optimal health. Black lives have been consistently imperiled in and through the biomedical encounter, in the form of lack of access to care and health insurance, inequities in caregiving, and the medical abuse of black bodies, from grave robbing for medical experimentation to the Tuskegee Syphilis Experiments and the appropriation of the Henrietta Lacks cell line.13 Anti-black racism continues to thwart black life and futurity through biomedical targeting operations that subject African Americans to what Du Bois named as a “social atmosphere . . . which differs from that surrounding whites.”14 Race-based targeting efforts that are aimed at redressing health inequities actually recursively secure this dominant epistemology of racial Otherness by refusing to acknowledge its structuring logic, thus equating blackness with inevitable vulnerability, risk, threat, and premature death.15 Importantly, while we focus mainly on blackness in this chapter (because citizenship/subjectivity has been constituted in relation to African Americans so differently to other racial groups in the United States), the medical apartheid set up through race-based targeting can and does extend to capture other racialized groups. This becomes particularly clear in our analysis of medical hot-spotting, where we see Latinx and native communities enfolded within—subjected to—such differential governing.16
Second, and related to our first point, these biomedical targeting operations extract the conditions of minority health and illness from the broader contexts of structural racism. By this, we mean that biomedical targeting generally fails to recognize the social conditions in which poor health emerges and how poor health, institutional racism, and the epistemology of racial Otherness are ontologically enmeshed. Indeed, the targeting of racialized populations—specifically through the two cases we explore here—does not simply direct resources to underserved groups. Instead, in such operations, race is objectified as that to be targeted, meaning that race itself is thus not undone: that is, race as a stratifying mechanism that orders the social is not called into question. Both BiDil and medical hot-spotting demarcate populations, with supposedly distinct bodies, and name them as a political problem in need of specific health governance; nonwhite bodies and racialized spaces are targeted in order to manage the life of the population. Accordingly, BiDil might be seen to ontologize blackness as a corporeal truth for market accumulation, while medical hot-spotting can be said to spatially ontologize structural racism to secure cost efficiencies of the health care system. BiDil is predicated on financial extraction; medical hot-spotting is predicated on threat containment.
These biomedical targeting technologies reveal how health interventions within contemporary biocultures of race-based health do not necessarily support or achieve a better future for underserved minority populations. Instead, they advance an epistemological violence by concentrating the “problem” of racialized life in the United States at the scales of (1) the racialized body (BiDil) and (2) space (hot spots), which both become objects of ever more heightened administration, financial exploitation, and securitization. BiDil positions African Americans as “problem bodies” that must take on responsibility for their own racialized embodied risk through the act of buying and consuming race-based medicine; here racial governance of health operates through the black responsibilization of risk. Medical hot-spotting tracks, maps, and fixes high-cost health care users in “problem spaces” that are positioned outside of the rest of the populace; hot-spotting locates and reifies the structural position of racial Otherness in space for the purposes of surveillance, anticipation of risk, and containment.
Third, contemporary biomedical targeting technologies are an endangering form of health administration exacerbated by the logics of neoliberalism. Under neoliberal conditions, populations previously excluded from the vital politics of the nation are now ostensibly being addressed. However, the two biomedical targeting technologies that we explore reveal a predatory power to demarcate race for purposes spanning financial extraction to threat containment (as we note earlier)—even as such “targeting” is advocated as the means for addressing the embodied and spatial effects of racial inequality. In neoliberal times, the color line no longer operates as a clear and obvious modality of exclusion, as Du Bois would have it.17 The neoliberal biopolitics of health increasingly emphasizes customizing health, the body, and life itself through biomedical practices.18 Our two case studies reveal how customizing health seems to be an operation of inclusion (directly or indirectly by race) within dominant biocultures of race-based health: BiDil is a customized drug that attends to black health; it targets African Americans supposedly to extend life. Medical hot-spotting is also a form of customization through care delivery: it locates “problem spaces”—where high utilizers of health care are located—to direct resources and generate efficiencies in health provisions. “Customizing” works in the first case through “color awareness” and marketing within biomedicine and the pharmaceutical industry (i.e., the racialized spectacle of the body) and paradoxically, in the second, through invisibilizing race at the level of location/space according to the so-called color-blind agency of the free market and cost–benefit analysis.19 While both targeting technologies may attempt to alleviate racial health disparities, they simultaneously augment racial difference and exacerbate racial inequalities—but they do so in very different ways: thus emphasizing the importance of tracing out the empirically distinct means through which each technology resecures the epistemology of racial Otherness. BiDil highlights the neoliberal refusal to acknowledge the social production of risk by casting health as an individual—not social—enterprise. Medical hot-spotting disavows the historical and spatial processes of racial formation that structure the present and simultaneously shows that certain (racialized) subjects are positioned—in advance—as risk failures within the paradoxically “race-neutral future” of the nation. To begin exploring these ideas, we turn to the case of BiDil, the oft-disputed first pharmaceutical with a race-specific indication.
Race Drugs: BiDil and Customizing Health “For Blacks Only”
On June 24, 2005, the New York Times announced that “the Food and Drug Administration took a controversial step toward a new frontier of personalized medicine yesterday, approving the first drug ever intended for one racial group, African Americans.”20 This new pharmaceutical, marketed as BiDil, targeted racial health and promised to both revolutionize biomedical attention to racial disparities and pave the way toward pharmacogenomics—where drugs and drug combinations will be optimized for each individual’s unique genetic makeup.21 According to the pharmaceutical company NitroMed (then owner of the patented drug), BiDil is “for use in addition to routine medicines to treat heart failure in African American patients, to extend life, improve heart failure symptoms, and help heart failure patients stay out of the hospital longer.”22
BiDil did not begin as a race-specific drug but, rather, became one through what Jonathan Kahn has called “a complex array of legal, commercial, and medical circumstances that transformed the drug’s identity.”23 The clinical trial that finally led to BiDil’s approval, the African-American Heart Failure Trial (A-HeFT),24 was conducted after many years of trying to get the drug off the ground: this trial enrolled only black patients, and NitroMed sought a race-specific approval because that indication had a longer remaining patent life.25 A-HeFT compared standard-of-care treatment plus placebo with standard-of-care treatment plus BiDil, a new combination of two existing generic drugs, hydralazine hydrochloride and isosorbide dinitrate. While the A-HeFT trial ended early—having convincingly proved that BiDil was beneficial for lowering the risk of death—it did not compare different racial groups and thus the trial did not actually prove race-specific efficacy. The FDA, however, cleared BiDil as only for use in black patients.26
Essentially, BiDil identifies, names, localizes, and depicts African Americans as a distinct group—that can be clearly demarcated—in order to make that group into an accessible “object” for the drug’s development, approval, marketing, and consumption. Within the broad biocultural arena, BiDil was identified as a necessary “good.” Organizations such as the Association of Black Cardiologists recognized BiDil as a means to address the specific health needs of African Americans and as a remedy for enduring health disparities to save black lives. The NAACP, too, backed the race-based drug by prioritizing the immediate needs of black individuals having access to medicines that would work—rather than focusing on the risks of the drug’s racialized designation. At the same time, however, many were wary of racial profiling in medicine and its associated risks and the way BiDil might further pathologize risk within the black body.
This latter line of thought directs attention to one of the key problematics of BiDil as an example of race-based biomedical targeting in neoliberal times: it reaffirms and ontologizes racial difference in the space of the body as a biological truth—at the genetic level. As Kahn has argued, “underlying the [BiDil] trial design is a race-specific patent that is premised on a genetic conception of race.”27 The FDA approval for BiDil was also ultimately predicated on this idea, as the organization gave its (and thus the state’s) imprimatur to the claim that African Americans had a different—and implicitly substandard28—physiology of the heart, attributable to some unknown but inherent biological factor.29 While the participants in the A-HeFT trial (that led to the FDA approval) were not genetically tested, “race” was used as a marker and a descriptor—a proxy—for genetics in the case of BiDil.30 Such a move problematically means that people with radically varying genetic realities are homogenized under the racial descriptor “African American.” It assumes that racial groups are biologically distinct (that there are clear lines between different races) and that African Americans represent a unitary racial group; it suggests that race itself is biological rather than a social category.31 As Troy Duster has poignantly argued, however, the issue of black heart failure “was not biological or genetic in origin, but biological in effect due to stress-related outcomes of reduced access to valued social goods, such as employment, promotion, housing stock, etc. The effect was biological, not the origins.”32
There is no denying that BiDil reduces heart failure. It is not clear, however, that it operates in a racially specific way. The deployment of BiDil as a “solution” to black ill health elides how the workings of anti-black racism register at the level of biology, as Duster suggests, and directs resources—a pill—at the effects of anti-black racism. This directing of resources at effects rather than causes reaffirms the correlation between biologically based notions of blackness and risk. Biomedical targeting, then, as in the case of BiDil, abstracts bodies from material space (and history) and naturalizes the historical conditioning of the black body as separate from template (white) “Human embodiment.” Indeed, BiDil might be viewed as a reinstantiation of the epistemology of racial Otherness in that the black body itself is viewed as the “problem” that needs a separate form of biopolitical administration. Ironically, then, while the pill might be seen as a way to decondition the historical accumulation of anti-black racism, it actually augments its operation.
The second key problematic highlighted in the case of BiDil is that such targeting can financialize supposed racial difference (and life itself) through customization and render this difference a market opportunity. Indeed, race—and specifically the supposed racial difference of African Americans—became the means through which to overturn the previous FDA rejection of BiDil and to create a niche market, rendering the black body a biocommodity33 or what Jonathan Inda has called a locus of “vital value.”34 What we see, then, is that nonwhite consumers represent an emerging growth market to be targeted by drug manufacturers precisely because of the high incidence rates of certain diseases within minority communities: while these diseases are themselves often caused by or exacerbated through operations of past and present biopolitical neglect, the biological effects of racial injustice become the basis for a profit-making enterprise.35
This BiDil marketing opportunity—located in the suffering black body—was spectacularly financialized: there was an estimated market of 750,000 black Americans out of a total 5 million people with heart disease who might benefit from the pill, and Wall Street analysts predicted “annual sales of US$500 million, even $1 billion by 2010.”36 Stock prices promised to be equally impressive, and in the lead-up to the FDA approval, BiDil stock crested at $29 per share.37 The part of the revenue that would stem from sales of the drug was to be secured through BiDil’s pricing structure: each pill cost $1.80, and patients would be required to take six pills per day. Had the drug been successful (ultimately, it was not), a regimen of BiDil would cost $10.80 per day and $3,942 per year, making the drug between four and seven times more expensive than the combined price for the generic drugs out of which it was made.38 Thus, despite the fact that BiDil ostensibly represented the fostering of life—of African Americans and, potentially, all patients—it did not necessarily support a better future for African Americans. If physicians were encouraged to prescribe this drug (to the exclusion of other therapies) because of its racial indication, yet acquiring it was financially prohibitive, then African Americans were perversely expelled from the opportunity to attain optimal health. BiDil clearly represented an exploitative accumulation strategy enabled through customization, one that would make money from black suffering. BiDil exemplifies how neoliberal race-specific biopolitics operates through racialized bioeconomics—the economic exploitation of the unequal conditions of racial life. It reveals an economic calculus that profits from the continuation of racialized ill health, which, ironically, the drug was meant to alleviate.
The third problematic of race-based biomedical targeting in the case of BiDil is that personalized care was implicitly framed as only achievable through the black responsibilization of health and risk. As Nikolas Rose has noted more generally, the contemporary biocitizen is called on to “partake of the ethic of active citizenship that has taken shape in advanced liberal democracies.”39 The idea—and attendant ethic—of active citizenship increasingly encourages people to self-care as a biological responsibility. Precisely because BiDil was approved and marketed as a heart failure therapy “for African Americans,” it presented an opportunity—and a call—for black subjects to attend to their health by way of consuming the drug. Two key factors should be noted here. To attend to health—to assume this responsibility—required that a new form of biosociality be inaugurated: a further collective identification of people of African descent, predicated now on supposed genetic sameness.40 The racial indication for BiDil required that blacks claim race as a biological truth, target themselves on the basis of this supposed truth, and govern themselves accordingly to fulfill the call to attend to health. Essentially, black subjects were entreated to “consume blackness” through using a designer black drug that, as we have outlined, was itself predicated on reductive and biologically essentialist ideas of race.41
Additionally, the “problem” of black health would be borne by the affected individuals. This individual responsibility for health is in line with neoliberal logics and practices more generally that have seen the devolution of state powers and collective securitization by the state and a shift toward the privatized and individualized government of risk. In the case of BiDil, it is evident that black health was cast as a biological factor for which African Americans need to be responsible—rather than a social product for which there might be a general social responsibility. The individualization of health can also be seen in the fact that the financial burden of BiDil would not be shared: Medicaid did not always cover the drug or states did not require Medicare plans to include it, and private insurance companies also denied coverage.42 Ultimately, then, the drug was put out of reach for the majority of those people it purported to help. This operation suggests a continuation of state and now privatized disinterest in African American health. The case of BiDil can be seen as exposing African Americans to a neoliberal expulsion from health: a drug that was ostensibly made to affirm black life was available but not made available.43 The irony is that such lack of availability, coupled with poor patient demand and the unwillingness of doctors to prescribe the drug, contributed to BiDil’s failure to secure the projected revenue and led to its eventual demise.44
Inarguably, BiDil can be viewed as a drug that offered (and continues to offer) the potential to affirm black lives, not by virtue of the racial specification, but by the simple fact that the drug has been shown to work. As Inda has powerfully argued, BiDil represents a way of realizing vital rights for black lives, a means to attend to racial health disparities, and a vehicle through which to materialize hope in communities affected by an excess burden of illness.45 But BiDil also problematically reifies anti-black racism in biomedicine and society more broadly and shows that drug companies can and have profited at the expense of the suffering black body. The meanings presented in the case of BiDil are inherently polarized and, indeed, contradictory, and it is this slippage—between positive and negative aspects of the drug—that leads Anne Pollock to characterize BiDil as a pharmakon, that is, as having “the capacity to be beneficial and detrimental to the same person at the same time.”46 Ultimately, however, the ontologizing of black health in the space (and as the property) of the black body resecures the ideas both that black corporeality itself is the “problem” and that blackness equates with risk, suggesting that, by and large, the detrimental aspects of the drug actually overwhelm the beneficial.
Locating the 1 Percent: Medical Hot-Spotting and Racialized Biosecurity
The contradictions and racialized hazards of biomedical targeting within contemporary biocultures of race-based health are further illustrated in our second case study, on medical hot-spotting. Medical hot-spotting refers to “a problem-solving technique that targets the most expensive problems or in-need people by allocating resources to specific problem areas as revealed by the data.”47 It endeavors to reorganize health governance according to the economic logic of cost efficiency by targeting populations that are “high utilizers”—that incur high costs—in the U.S. health care system.48 The practice began in Camden, New Jersey, an economically depressed community across the Delaware River from Philadelphia. Following the collapse of its industrial base and decades of disinvestment, Camden effectively became a container of poverty within a deeply racialized region, with declining interior infrastructure and minimal access to outlying areas where services were being elevated and communities cultivated.49 The city of Camden today hosts a slew of toxic industries, from incinerators that burn Philadelphia’s trash to pharmaceuticals manufacturing. The city’s housing and infrastructure are largely unsafe or abandoned, and the population (~77,000) is per capita one of the poorest in the nation.50 In 2006—just prior to the adoption of medical hot-spotting—the median household income in Camden City was $18,007, the lowest of all U.S. communities with populations over 65,000, and 52 percent of the city’s residents lived in poverty.51 These figures become particularly telling in light of the racial demographics of the city: according to the 2010 census, half of the city’s residents were black or African American, and more than a third of the residents were “Latino or Hispanic.”52 Widespread industrial contamination, poverty, and escalated violent crime all have contributed to a dire public health problem in Camden. With 29.5 percent of the population unable to afford prescription drugs, the city’s residents clearly experience disproportionate levels of ill health.53
The innovations of medical hot-spotting emerged in this racialized context as a means to lower exorbitant health care spending on the medically indigent by coordinating intensive outpatient care for complex high-needs patients.54 The practice involves locating costly users of the health care system and targeting them for more effective, preemptive care to cut down on the number of medical crises requiring expensive treatments and rehospitalizations. To achieve this, medical hot-spotting applies policing strategies to health care, namely, the methods of tracking and mapping crime statistics to direct police to “hot spots” of criminal activity.55 The medical application of this police technology uses medical data to identify populations that are high utilizers or “super-users” of the health care system, that is, patients who use health care resources at abnormally high rates. Medical hot-spotting in Camden revealed that 1 percent of patients were driving 30 percent of medical costs and that people with the highest medical costs and the greatest number of emergency room visits were usually receiving the worst care.56 One single public housing development was alone responsible for $12 million in health care costs from 2002 to 2008.57 High utilizers of health care in Camden visited overburdened local clinics; they were uninsured or otherwise remiss about seeing a primary care doctor for preventive care, were on welfare and otherwise poor, and were purportedly making detrimental lifestyle choices with little capacity for change.58 By targeting these concentrated zones of high utilizers through spatial data analysis, medical hot-spotting seeks to organize and tailor care management through numerous techniques that restructure the organization, delivery, accountability, and doctor–patient relations of health care, from interdisciplinary teamwork to house calls and behavioral modification techniques (focused on an individual patient for up to six months).59 A promising aspect of medical hot-spotting, then, is its potential to alleviate health inequities, through stabilizing both the medical conditions and social environment of patients as a means to health. This might entail health and 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.60
From its Camden origins, medical hot-spotting has gained traction across the health care system. Similar practices are now at work in places such as Trenton, Newark, West Philadelphia, York, Scranton, Allentown, the Bronx and Queens, Atlantic City, Boston, Anchorage, Chicago, Seattle, and Las Vegas.61 Such health care reforms and experimentations are needed social projects, which, we argue, are always inherently racial projects.62 Indeed, the well-documented institutional racism of biomedicine and persistent forms of structural racism that underpin U.S. society and produce differential vulnerabilities to illness and disease are part of what universal access to health care endeavors to address and even rectify.63 Yet “race” remains topically out of bounds in discussions about medical hot-spotting. Our contribution, then, is to consider the racialized operations and potentially inequitable and endangering effects of medical hot-spotting as a relatively new practice of targeted health interventions. While BiDil might be said to ontologize blackness as a corporeal truth for market accumulation, the neoliberal logics and spatial technologies of medical hot-spotting work to ontologize racialized spaces—they ontologize structural racism as space, as transparent/self-evident, race-neutral, dehistoricized, undialectical space. Regardless of the intentions behind medical hot-spotting, it potentially supports intensified racial dominance under the auspices of improved health administration and biosecurity. We explore here three developments on the horizon of U.S. health care reform that rationalize the epistemology of racial Otherness through intensifying forms of monitoring and containing costs. Such speculative analysis is timely given the mounting popularity of medical hot-spotting under the banner “when treating patients like criminals make sense.”64
First, medical hot-spotting mobilizes a national imagination of scarce health care dollars and advances a world defined by a grid of relationships of cost that fuels racial enmities.65 The abstraction of this cost grid disregards the “richness” of space—the social–spatial relationships that contribute to high-cost usage of health care—and it circumscribes subjectivity within the market. Managing medical care for cost containment disregards the structural reasons for ill health by giving epistemological primacy to cost relations.66 There are countless examples of this circulating in the media: “there’s a small segment that is burning through 20 percent of our society’s wealth at a massive rate” or “because U.S. hospitals give billions of uncompensated care to the uninsured and under-insured each year, they pass costs along to insured users.”67 In the context of austerity policies and widespread panic about the overtaxed U.S. health care system, “cost efficiency” amplifies a racist antagonism between those who are worthy of scarce resources—an imagined community of deserving Americans, that is, white, suburban, healthy families—set against the despicable, leeching “high utilizers,” a category that serves as a proxy for racialized others. The call to locate the super-user 1 percent marshals racism via the powerful rhetoric of statistics and unfair burden. We may see “high utilizer” join “welfare queen” and “gangbanger” in the pantheon of demonized subjects for “endangering our national health care budget and the health of worthy citizens who are not bringing health problems on themselves.”68
Medical hot-spotting, then, easily supports the idea that hot spots are a threat to the nation and, by locating them, facilitates the transfer of blame and placement of responsibility on those who are already disadvantaged and disenfranchised, that is, those who inhabit these spaces. The super-user is identified and “found” through hot spot delineation, where the inhabitants-as-threat inhabit the space-as-threat, and vice versa. This is particularly deleterious to African Americans, who have received significantly less adequate care than white Americans because of a host of financial, organizational, and social barriers.69 The historically accumulated suffering of the black body has meant that African Americans are at increased risk for acute and chronic diseases, epidemics like HIV/AIDS, and mental illness.70 But disease burden and disparities in health exist across a range of racial and ethnic groups in the United States. For example, Latinx populations as a whole experience higher rates of diabetes, HIV infection, tuberculosis, cervical cancer, stomach cancer, liver cancer, and liver disease than whites.71 In American Indian and Alaska Native adults, the age-adjusted death rate far exceeds that of the general population—by almost 40 percent—and deaths due to chronic liver disease and cirrhosis, tuberculosis, pneumonia and influenza, and heart disease also exceed those of the general population.72 Health disparities also exist within the Asian American and Pacific Islander communities: Asian Americans experience the highest rates of any racial or ethnic group for liver, uterine, cervical, and stomach cancer;73 Asian Americans and Pacific Islanders have greater incidence rates of tuberculosis and hepatitis B than any other racial or ethnic group; and Asian Americans experience higher rates of diabetes than whites.74 The risks of racialized life in America are eclipsed, however, by operations that stratify the population and justify the harmful impacts of neoliberalization experienced disproportionately within certain minority communities.75 Targeting the 1 percent of the U.S. health care system enacts a deeply structural logic of racism, equating racial difference with the antithesis of the ideal neoliberal citizen—as inherently vulnerable, risky, wasteful; as unable to be self-sufficient or healthy; and as a burden to the nation.
Second, medical hot-spotting promotes self-care in the absence of social welfare and thus contributes to a feedback loop of racial domination. Lack of health is attributed to personal failure rather than the structural positioning of black and brown subjects outside of the populace to be fostered, and the aggregation of these failures is mapped in space for the purposes of surveillance, anticipation of risk, and containment.76 While autonomy and empowerment to make oneself be healthy are laudable goals, the neoliberal imperative to “self-care” undercuts the promise of social reform by enlisting the nation’s costliest health care consumers to participate in preventive care—a process that relegates racially coded economic, social–environmental disadvantage to the private and personal spheres.77 Neoliberal self-care asserts that individuals are solely in charge of their health and should adjust their behavior to achieve optimal health; individuals who fail to do so are “bad,” deviant, or even pathological subjects, despite any structural issues that might preclude good health. Under neoliberal logics, minorities are enlisted to self-care—to participate as consumers of preventive care—yet any inability to do so is relegated to a private issue or racially grouped failure within a supposedly color-blind meritocracy enabled by the free market.78 Thus, medical hot-spotting potentially resecures the epistemology of racial Otherness through requiring racialized subjects to take on self-responsibility as if it were race transcendent.
The practice seeks to intervene in the daily care of three categories of patients—the mentally ill, the medically fragile elderly, and patients who are described as “socially disintegrated,” that is, “those who tend not to engage in self-care, have few family resources and display dependent personalities.”79 The category of “socially disintegrated” seemingly offers an opportunity to examine the race-specific biopolitics of health—how poor health, institutional racism, and the epistemology of racial Otherness are ontologically enmeshed. Anecdotal evidence and a short documentary about medical hot-spotting demonstrate that medical hot-spotting does attempt to expand health care into social, environmental arenas and to cultivate social infrastructure and stability through caregiving.80 Such efforts, however, are undermined by the behaviorist emphasis, which medicalizes urban marginality. The sorting out of the so-called socially disintegrated—those who fail at/to self-care—from productive citizens allows for race to be understood as a marker of risky or dysfunctional social behaviors rather than an indicator of racialized knowledges and experiences that make one more vulnerable.81 Medical hot-spotting signals a shift in health governance toward potentially more aggressive in/voluntary programs that target individual behavior and mandate personal responsibility, as the state is withdrawing institutional supports that are necessary to shoulder illness, unemployment, indigence, and so forth.82 The practice could progress in the direction of racially sorting and segmenting health care to support moralizing behavioral workfare in the context of austerity and corporatized health care.
Third, medical hot-spotting risks spatially ontologizing historical geographies of racial domination—urban renewal, redlining in housing and mortgage industries, environmental racism—as simply geodemographic “facts” on a map. From crime mapping and policing, medical hot-spotting borrowed technologies (namely, 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 hot-spotting generates digital cartographic representations of high-crime areas by linking statistical information, such as crime type and occurrence, with zip code and neighborhood.83 Police are then able to target anticipated high-crime spaces by spatially customizing surveillance and control.84 Similarly, medical hot-spotting integrates GIS data and demographic techniques that target problem spaces and populations through spatial profiling.85 Such geosurveillance is the logical outcome of the militarized interpretation of residents as risk factors that need to be logged, mapped, and understood in a calculative statistical manner. Medical hot-spotting secures target fields of information, spatial data, and geographical identification of high-risk people and spaces for the purposes of biosecurity, that is, managing health for the optimization of the population.86 The auditing process—the geographical processing of medical metadata—generates a racially stratified datascape of expectations that basically reproduces “what we already know.” The spatial ontology at work in this targeting operation stipulates that where you are reveals who you are, as collected, assessed, and defined by marketers, governments, the police, or clinics.87 Racialized spaces and bodies become ontologized as knowable, measurable geotags and data of a population—even when medical hot-spotting does not explicitly involve racial profiling. In other words, medical hot-spotting ontologizes structural racism in/as space.
Medical hot-spotting’s application of GIS demonstrates a political rationality that calls forth surveillant uses of technology in the observation of spaces and populations, transforming governing into a field of perception.88 The geosurveillant technologies that inform medical hot-spotting arguably mobilize the ghetto as a preemptive way of seeing, of knowing-as-containing.89 Thus, establishing medical hot spots may serve as a teleological spatial containment technique for the management of poverty and marginality.90 Targeting the medically indigent 1 percent could result in “coordinated care camps” that punitively quarantine racialized segments of the population by restricting access to specialized medicine and experts. Stricter definitions of medical necessity may be instituted within hot spots to decrease opportunities to receive a particular test or treatment (a twisted reversal of current profit-seeking methods that overprescribe to the poor, such as ordering unnecessary tests or visits). Basically, medical hot-spotting allows for—even rationalizes—racially segmented care by drawing out and further entrenching social borders and spatial segregations. In other words, minority communities might experience medical hot-spotting as an intensified form of medical redlining, that is, “spatially customized care” as a means to ration medical resources and health care. Given the twin neoliberal imperatives of cost containment and self-care, it is not a stretch to see medical hot-spotting even develop into a remote-sensored care delivery system that somatically surveils the high utilizers of health care through cost-saving home monitoring, informatizes corporeal systems to mine data, and positions bodies as nodes within a network of physiological, behavioral, and locational data connected to command centers.91 The geosurveillant technologies of medical hot-spotting reveal that health promotion and disease prevention involve increasingly militarized preemption, concentrated in preknown spaces of failure as analytic objects that can be surveilled at a distance.92 Whether through self-responsibilization of risk or ontologizing structural racism in space, medical hot-spotting reveals the future of a race-specific biopolitics of health that rationalizes and defends racialized biosecurity as race-neutral technology.93
Abolitionist Biomedicine: Refusing This World
The Du Boisian vision of alleviating the racial “cut” in the governance of life has yet to be realized. In the era of neoliberal biopolitics, minority lives are imperiled in the very same moment that life is ostensibly affirmed. Biomedical targeting technologies are predicated on the seemingly laudable pursuit of attending to vulnerable populations and alleviating racial disparities of health. These technologies potentially address specific conditions of racial inequality, in accord with Du Bois’s call to attend to the color line. In the contemporary era, race-based pharmaceuticals and medical hot-spotting bring underserved subjects into the fold of the vital politics of life through customizing care at different scales of existence—the individual body and the environment of certain populations. Yet, in doing so, as we have shown, these practices continue to ontologize those bodies and spaces as a problem. Thus, although they may not explicitly fortify the color line in the Du Boisian sense, they more ominously resecure racial division through the supposed fostering of life. The targeting of specific bodies or spaces extracts them from broader relations of structural racism and customizes medical resources in ways that objectify race or racialized space as that which should be secured against. Ultimately, such biomedical targeting recursively protects the reality that health optimization is an exclusionary project.
Our main intervention has been to examine the epistemological underpinnings of race-based health initiatives. Our two examples of BiDil and medical hot-spotting show that biomedical targeting anticipates risk and failure and performs death-expectant interventions that ultimately expel racial minorities from optimal health—but do so in different ways. BiDil extols black responsibility of risk, enlisting African Americans in self-care for lived and embodied conditions of anti-black racism—that is, for violence against blacks and for historically accumulated disadvantage and ill health that result from the positioning of African Americans outside of the category of Human. Medical hot-spotting further demonstrates the enduring workings of the epistemology of racial Otherness—through identifying “problem spaces” inhabited by “problem bodies.” The practice orchestrates violence through spatial abstraction and data-based mapping operations that contain and surveil race as a threat, and, like BiDil, it calls for individualized responsibility. In short, such targeting fails to cultivate nonwhite futures and, instead, ontologically secures minority status as nonfuturity.
Futurity lies at the heart of biopolitical governance and practices, which intervene into life not only to control but also to improve the prospects of the population. In a Foucauldian understanding, biopolitics exerts a positive influence over life “that endeavors to administer, optimize, and multiply it, subjecting it to precise controls and comprehensive regulations.”94 Yet, if health, as we have shown, is an exclusionary achievement, it seems imperative to work to abolish race as an operation that biopolitically adjudicates. To this end, biomedical efforts that seek to organize reparative justice must work against reestablishing race as an ontology at the very same moment that we labor toward alleviating those very real social disparities predicated on race.95 As such, a just politics would need to address race (and ethnicity) as the basis for health. Essentially, such a politics would refuse this world, precisely because it is structured through dominant epistemologies of race and “looks like no future at all.”96
There is a strong history of these kinds of abolitionist medical efforts in the United States. For instance, President Johnson’s “unconditional war on poverty” in the 1960s saw the establishment of the Office of Economic Opportunity, which funded the earliest form of community health centers in the United States. Such centers not only delivered face-to-face medical care to minority and poor individuals but also addressed the causes of poverty and the social etiologies of disease—looking to improve the social and environmental determinants of health: “they repaired old housing, built clean water and sanitary systems, organized food cooperatives, cleaned up environmental threats, created local transportation systems, developed potent community organizations, and—most important—trained and hired local residents as health workers at multiple levels, and opened pathways to professional education.”97
In the 1970s, the Black Panther Party also advanced a range of health activism projects, based on their understanding of the links between race, economic disparities, and poor health. As part of their strategy to expand services in underserved communities, they operated numerous health clinics across the country—addressing health concerns in black communities, such as screening for sickle cell anemia. They also developed “survival programs” that pursued what Alondra Nelson has called “medical self-defense.” The Free Breakfast for Children program fed more than twenty thousand children every week, with the aim of maximizing health. They offered community classes in economics, first aid, and self-defense; developed programs that provided drug and alcohol rehabilitation; supplied groceries and clothing to those in need; and organized escorts and advocates for seniors to attend medical appointments.98 More than this, however, the Black Panther Party called for free health care for all black and oppressed peoples, highlighting the linkages between poverty and medical marginality regardless of race. In their revised 1972 Ten Points Program (the Panther Party platform for action), “health” was formally added as point 6—and reflected this commitment to health activism across racial lines:
We believe that the government must provide, free of charge, for the people, health facilities which will not only treat our illnesses, most of which have come about as a result of our oppression, but which will also develop preventative medical programs to guarantee our future survival. We believe that mass health education and research programs must be developed to give Black and oppressed people access to advanced scientific and medical information, so we may provide ourselves with proper medical attention and care.99
These historical examples highlight as much about what will be needed in the future as they reveal about the past.
Clearly the challenge continues, as evidenced by continued health disparities based on race, ethnicity, and poverty. The largest health gap is still race-based, between blacks and whites, in the United States. Black Lives Matter organizing and the practice of medical die-ins (part of the broader Black Lives Matter movement) have recently sought to address these enduring realities.100 In response to the preemptive violence aimed at black individuals—and the long historical precedence of coercive force under which black people have been prefigured as threats in the United States—the multisited Black Lives Matter movement calls out and refuses the foundational logics of race, which only recognize and privilege white life and which position blacks as a population against which society must be defended. This refusal is enacted through the naming of a project not yet realized: that black lives matter.101 The chant calls on people to repudiate the lethal conditions of living out the biopolitical cut of race in America—of no future for black lives—by asserting what biopolitical futurity has yet to achieve: the so-called universal value that all lives matter.
Provocative protest actions, such as die-ins, confront racism dispersed throughout the spaces of everyday life as a means of revealing and refusing anti-black violence. During a die-in, groups of protesters “play dead” in public spaces, lying down en masse in the middle of intersections, train stations, lobbies, classrooms, public squares, and so forth.102 The momentary overlay of a symbolic mass grave of bodies vividly portrays the biopolitics of disposability at work through the operations of race in the United States.103 The die-ins are opportunities to publicly mourn the mounting losses of black lives and to reject the unjust threat to be killed that African Americans confront merely by going about their everyday lives. While die-ins are part of a longer history of civil disobedience and protest efforts, the Black Lives Matter mass actions insistently demand witness to the long-standing and ongoing subjection of African Americans to coercive force and exclusion from public life and health. Performing an iteration of the die-in, parts of the medical community have engaged in Black Lives Matter organizing through medical die-ins or “white coat die-ins.” Protesters, usually medical students, lie down motionless, as if dead, on hospital and clinical floors, while wearing white coats—what has become the conventional “uniform” of doctors and a symbol (however problematic) of scientific authority, healing, and responsibility for saving lives. Medical die-ins visually reference and reverse power relations and professional roles within the medical establishment: those who are charged with saving lives paradoxically drop dead.
While medical die-ins could be looked at as supporting more resources for customizing biomedicine, the very performative act of the die-in suggests a move away from the medical environment to a more expansive envisioning of racial justice—echoing the movements we cite earlier and the more general range of efforts advanced through community health centers. This momentary refusal to be instrumental to pervasive medical institutional racism—and the effort to link biomedicine to broader social relations—powerfully draws connections between police brutality against blacks and the protocols and practices of the U.S. health care system that have led to poorer health, shorter life expectancies, and inferior medical care for black Americans.104 The collective action of suspended medical professional operations—of enacting protest as a professional obligation to public health—opens up the potential to address the role of explicit and implicit forms of discrimination and structural racism in clinical learning environments, medical administrative decision-making, medical education curricula, and daily hospital operations that affect not only blacks but the range of minority and poor individuals in the United States. This form of collective action advocates for future abolitionist practices that refuse to resecure race as the problem: that reject the racialized biopolitics of health because it “kills, sickens, and provides inadequate care” and that publicly excavate—and mourn—the ruins of nonfuturity that are our institutions.105 And, while the same doctors or medical students might support race-targeted pharmaceuticals and race-based coordinated care, surely what is needed is something more imaginative and visionary than prescriptive and constraining reinstantiations of racial essentialism as the means through which to cultivate life.106 What remains, then, is the question of how such a refusal of what is might translate in the present moment into practical efforts toward an abolitionist biomedicine—in relation to both care delivery and drug development—to rework the biopresent and pursue alternative biofutures.