What is the role of the 911 ambulance in the American city? The prevailing narrative provides a rather simple answer: to save and transport the critically ill and injured. This is not an incorrect description, but it is incomplete. The ambulance plays another role, one that is less known. Along with other frontline institutions like the prison and welfare office, I argue the ambulance is part of a poverty regulating regime that is focused less on the eradication of material suffering and more on the day-to-day management of its symptoms.

I draw on nearly two years of fieldwork (including 9 months working as a novice emergency medical technician) and over 100,000 medical records to reimagine the ambulance as an institution of poverty governance. Against somewhat common assumptions that this vehicle is absent or tardy in poor neighborhoods, my research demonstrates that the ambulance is actually a prevalent and busy institution in these areas. Not only are the poor more likely to experience life threatening crises, they are also more likely to summon the ambulance for so-called non-emergencies.

Whether by compressing lifeless chests on the streets or by transporting the publicly intoxicated into the hospital, ambulance crews daily transform the bodies and spaces of urban poverty. This work brings them in recurrent contact with the emergency department nurses and police officers who share their clientele. I show how these different workers often conflict over the management of subjects they generally see as burdensome. With “legit” ambulance calls being relatively rare, crews frequently struggle with police and nurses over “bullshit” work. These street-level relations, however, cannot be understood without considering the forces that control and coordinate labor from above. Neoliberal principles of organizational efficiency and flexibility have flooded poverty governing institutions throughout the American city, and the ambulance is no exception. The state often delegates paramedical operations to for-profit agencies that run on a fee-for-service model. This intensifies the exploitation of labor and exacerbates tense relations between crews and their clientele on the one hand and crews and their nurse and police counterparts on the other.

My research advances a new framework for understanding the management of marginality: the labor theory of poverty governance. This model insists that we cannot understand how the poor are governed without understanding the labor process that generates and re-generates the poverty regulating state. This means accounting not only for the interactions between laborers and the subjects of their labor, but also the horizontal interactions amongst laborers and the vertical interactions between laborers and those who control and coordinate their work. This framework is novel in that it integrates three crucial dimensions of poverty regulation: the frontlines of governance, the horizontality of governance, and the verticality of governance.