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Is Health Care a Democratic Right?

The bulbous, bloated cartogram meant to render the prospective withdrawal of insurers from individual health-care exchanges under the Affordable Care Act in its deepest colors foregrounded the concentration of a reduced insurance market in rural areas.  The image of a nation seething over, and the ground boiling over as if with discontent, cartogram, distorted “red” and “blue” states alike, but seemed evidence of the ways that the Affordable Care Act warped the even playing field in the United States–as if that ever existed, and could be expected to exist today.  But it might be taken as an emblem of the deep anger and resentment that many areas of the United States felt toward what was labeled “Obamacare,” and the regional markets left with but one insurer–and an inevitable feared rise in their insurance premiums–in the health insurance markets that the Affordable Care Act would create.

The designers of the cartogram warped to counties’ population almost aptly if inevitably rendered the country as boiling over with anger:  it seemed to render a powerful emblem to justify if not inspire broad indignancy about the apparently uneven consequences of mandated insurance exchanges which it argued the less populated–and poorer–areas of the country would be stuck with, as a distillation of social injustice.  For the cartogram captured what its designers argued was the distorted market for health insurance which people on the coasts had designed as destined to shut out large areas of the country shaded in lighter colors–and prevalently light pink.  But the prediction of a contraction of providers that undergirds this ominous scenario, as we now know, didn’t come about at all,–even if the strong passions provoked by the fight over health care did leave the country boiling over with anger and indignancy widely felt to be objectively justified.

 

map2_20170725Warped Map on Insurers Red v Blue Goves

It can be quite forcefully argued that health care deserves to be regarded as a  democratic right–democratic with a “small ‘d,'” in the sense of an egalitarian right, even though debates about access to health insurance are increasingly cast in politically partisan terms.  Although access to insurance exchanges are increasingly treated as a question less of a right than the reflection of a political position, the proposition of guaranteeing health coverage is rejected by champions of the marketplace and its benefits, who argue that its falsity undermines a free market.  As a result, in part, health-care exchanges are increasingly mapped in terms that might well be mistaken for political partisan divisions within the fabric of the nation.  Indeed, the sharp, flat blues, reds, and deep carmine of different regions suggest the hopes and difficulties of providing a uniform insurance plan for a nation of radically different numbers of insured, facing the hope to provide more with coverage in a way that may seem to tilt against the open nature of the marketplace.

 

Us Marketplaces.png

 

But democratic rights include not only political participation but due rights to certain benefits that accord undeniable liberties.  And although liberties which were not defined as including health care in the eighteenth century, leading many strict constructionists to view health insurance as an excessive presence of the state in individual lives, the range of liberties have expanded to-liberties to education, or to health, or protect against race-based, ethnic, or sex-based discrimination–revealing the broadening scope of understanding liberties, and might be  mapped into the fabric of the nation as an individual rights, and a basis for ensuring greater egalitarianism–and social equality–as a right.

 

Obama-healthcareBlack Enterprise

 

Back in 2013, of course, the institution of health-care exchanges set up a new landscape of the Patient Protection and Affordable Care Act–the Affordable Care Act or simply ACA–allowing most Americans to buy insurance on  government-run exchanges (or marketplaces) to have access to health care that they were often lacking in all fifty states, creating the reign of designing data vis of Obamacare exchanges often subsidized by the government for those eligible, to make it available to all, in ways that created some thirty-six exchanges run with the federal government, as states ran the others alone–creating the odd scenario that more enrollees came from red states, where they were run largely by the federal government.

 

state-health-insurance-exchange-landscape

 

But this was not widely accepted, and the rejection of the promise of what is now widely labeled Obamacare reflect the deep divides that its opponents argue the government mandate for buying insurance policies will impose on the nation.  The online popularity of recent projections of a constriction of health insurance options for most counties of the nation that were proposed as recently as the spring of 2017 seemed to reveal the deep dishonesty in the proposals of the Affordable Care Act to level the playing field.  And although the capital of health care as a good to the nation demands to be mapped, the difficulty of parsing the ACA independently of the name of Barack Obama reflect the unfortunate polemic level of debate about seeing adequate health insurance as a right of all–even as fear of losing health insurance dramatically rose across the nation, and the fears of rising premiums posed by its mandates were widely stoked by data visualizations suggesting widespread abandonment of insurance exchanges.

 

Changes in Providers.pngUS Health Policy Gateway

 

The data visualization–which almost amounts to a tool of outright propaganda–uses flat carmine to blanket the real improvements in numbers of the uninsured.  The presentation of an apparent distortion of the market is confirmed by declining insurance policies available on Obamacare exchanges, as its accompanying text assures readers that the real people to benefit from “marketplace enrollment” was the “private health insurance industry” who gained $90 billion in premiums, greatly profiting “publicly traded insurance companies”–distorting meanings of “public” and “private” as if to imply the dystopian nature of health exchanges that benefit coastal states alone.  The map of possible changes in rates of premiums were even more striking, and was presented as evidence of poor policy planning, as well as signs of a grim “slow motion death spiral”–a strategic choice of term suggesting the poor level of health-care it provided, and organically faulty nature of its establishment, but alienating the numbers of premium growth from individuals covered.

 

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The familiar series of sequential images forecasting the mass exit of insurers from exchanges over a period of four years of the adoption of Obamacare stand at odds with the fears of losing health care and the defense of health care as a right, as well as a national system of insurance.  And despite an onslaught of maps  ostensibly demonstrating the ever-narrowing options for individuals as available insurers in state-based exchanges  dry up; they convey an imaginary future in which few counties with “active markets” of four or more alternatives–apparently compromising the rights of many Americans.

 

nssustaniable decline

Bloomberg Graphics/2017 Health Insurer Exits (projected)

 

Indeed, the image of rapidly dwindling options faced by Americans that such data visualizations claim to be based on data from HealthCare.gov. seem to suggest a focus on individuals.  But the broad brush strokes leave little to the imagination and present an ominous emptying of choice that seems designed to induce panic.  The images are executed with great dramatic effect, but little sense of cartographic skill–they presented a dire picture in which four options would be only available to residents of eight to ten states by 2017, calling into question the ability of much of rural America to remain insured.  The images of rural abandonment by health care exchanges were particularly powerful,  so absolute in their predictions as if to afford little room for interpretation

Yet the projections, for all their power, stand at variance with reality.  There will be, we now know, in fact no Obamacare marketplaces that remain at risk of being without insurers in 2018, as of August 24, 2017–

 

w:o insurers in echange

–and but a smattering of counties that were at risk for being without any insurers:

 

at risk of no insurer

Kaiser Family Foundation Interactive Version/Open Street Maps:  Counties at Risk of Having No Insurer on the Marketplace in 2018 as of August 24, 2017

 

In short, the disruption of the narrative of a dwindling of insurance options has been, after the failure to repeal the ACA, dramatically disrupted.  Even while acknowledging that there was a record low of uninsured in America after the American Care Act was adopted in “Obamacare marketplaces”–a coded term if there ever was one, loaded with disparagement–data visualization were crafted to predict deteriorating coverage options deteriorated in the months ahead in many rural states of apparent objectivity; hastily created maps, at an odd angle to reality, suggested that as much as over a fifth of all federally run marketplaces–predominantly in rural areas–were with only one insurer.

The alleged “bolting” of insurers from such marketplaces were predicted to leave areas like eastern Tennessee without any insurers, like, perhaps, southern Georgia, much of Colorado, almost all of Iowa, many counties in Ohio,  and large numbers of Virginians, as Aetna, Wellmark, and Anthem were predicted to “bolt” from the exchanges, leaving those Obamacare “customers” high and dry.  The argument of the abandonment of rural America was particularly grim.  But as the projections of the “bolting” of insurers fail to acknowledge the sparsely populated nature of many rural areas, the story that they tell of magnifies the poorly managed nature of the marketplace, obscuring the benefits or rights to health care–and the reduction of the number of uninsured across America– that the ACA has managed to create.  By privileging the size of largely unihabited regions of the midwest, maps of uninsured counties presented a decidedly skewed picture of enrollment, where the square miles covered by insurers projected to participate in health exchanges  seemed to outweigh those where insurers participated, irrespective of the sizes of inhabitants.  It is perhaps no surprise that support for Trump’s candidacy did not correlate with support for the ACA–

 

ACA-support-HaystaqDNA-score-by-county

 

 

We focus on individuals to measure popularity for the support for health care reforms across the country.  Although many have recently entertained sustained interactive levels of introspection about where Americans supported  the Affordable Care Act in the months that preceded the election, pouring over the support for the ACA through county-by-county lenses that made sense pretty much only in how they might translate into votes.

While moving toward the acknowledgement of health care as a right is independent from such measurement of support for the ACA, the  low support for the act in sparsely populated areas intensifies as one moved to less populated areas, by and large, to suggest poor penetration of exchanges into much of the nation–and the distance of health care from what seemed in square miles a quite considerable geographic area.  Resistance to the ACA however reflects a rejection of the broad classification of health care as a right–or to even start to affirm it as one nation.   The division of the country, while reflecting the red state/blue state map in many ways, suggest pockets of counties with strong support for the ACA in a surprising range of the south, southwest, and other regions–across the divide between red states and blue.  Haystack’s micro targeting models estimated just under 98,943,000 ACA supporters nationwide–wondering how the electorate would parse on such a push-button issue.  And, indeed, the Senate Republicans were quick to issue a somber grey data visualization that affirmed a clearcut divide suggestive of the status of yellow- or red-alert in areas “abandoned” by Obamacare– in an openly partisan moment, undoubtedly funded by tax dollars.

Senate Republican Party flawed policies 2018U.S. Senate Republican Policy Committee

 

If over a third of the nation, colored an arresting yellow, seem to flounder in facing monopolies of insurance in the image that the Republican Policy Committee in the United States Senate designed for public consumption, who seem to have sought to raise a yellow- or red-alert for subscribers of Obamacare being abandoned, the map foreground  a divide in deeply partisan ways, failing to note persistently steep inequalities among  uninsured across the states, and the difficulties to attract insurers to markets in equal numbers, particularly in regions where up to a fifth remained uninsured in 2001-3.

 

% Uninsured 2002-3.png

 

 

Despite some questions of whether Republicans would be “alienating their own voters” didn’t affect the results of 2016 congressional elections.  But the power of the continued threat of a coming “implosion” of exchanges that upset the level playing field as an inevitable occurrence was successfully manufactured in projections of insurance markets that peddled groundless prognostications as if they were objective fact:  they successfully mobilized fears of the ability to avoid or precipitate a coming crisis by making it concretely manifest for viewers, pushing many to question the benefits that the extension of the ACA would actually bring–and to see it as a promise that would not be able to guarantee continued coverage or familiar premiums, and indeed to be engineered by the coastal elites and insurance companies that so much of the country has already come to distrust.   For the data visualizations that projected the uneven playing field that exchanges would create cast a divided commonwealth as a result of the limited choices restrictive options of health insurance many Americans would face.  These visualizations raised significant alarms bout the fate of Obamacare–and the specter of its undemocratic nature raised questions of what it provided to the country, or what future it might bright–that were deployed in particularly effective ways.

Flat colors of a data visualization communicate as many falsehoods about its actual relation to people as Trump’s favored declamation of Obamacare “very, very bad insurance.”  They obscure satisfaction ratse of over 75% among those enrolled in plans, and of almost 90% in public Medicaid programs for the poor.  Rather, the picture of an implosion of insurance markets garnered ungrounded trust, and became demonized as but “a first step” toward what he presented as the apocalyptic scenario in which the “government basically rules everything”–a fear of the implosion of a free market–ignoring that the American Care Act is premised on encouraging competition among medical insurers.  Yet the image of such an implosion or collapse perpetuated in data visualizations of crude colors was something that was manufactured in projections that masqueraded as objectively designed maps.  In charting decreasing insurer participation in exchanges as actualities, data visualizations seem designed to stoke uncertainty about the future viability of health insurance markets in America.  Yet the uninhabited nature of this landscape of counties–a metric that makes sense only really as a convention of electoral politics, rather than health care or even of individuals residing in different parts of the country, is starkly removed from health care save in terms of how it might translate into a political choice.

The rhetoric of these “maps” uses projections cover the individuals who benefit from medical care.  They encourage voters to feel slighted in new medical marketplaces, and ask them to chose a future–without considering metrics of coverage or the relative quality of medical care.  They serve to map a landscape of fear, encouraging fears of growing premiums and less choice among voters in what is painted as a compromised medical marketplace.

 

1.  Construing health-care as part of a democratic system has been understood in surprisingly partisan terms.  Some would restrict liberties to participation a marketplace, by adopting and privileging the market as a primary metaphor if not end of civil society:  the success of such a distinction has lead to a broad and striking demonization of its mandate, rather than the policies of the health care law signed in 2010–the Affordable Care Act–which as a law has consistently received far less opposition than the change in health insurance provision that mentions President Obama’s name.  The divide in perceptions seems to have been broadened considerably by recent visualizations that project the future market for health care, or project the numbers of insurance carriers available in exchanges, the colors of the availability of carriers overwhelms the presence of individuals, and reveal the new markets that the Affordable Care Act (or ACA) created as if it were an uneven playing field for all Americans.

Indeed, as recently as June 2017 and during the Trump-Clinton campaign, media outlets and websites trumpeted “maps” or “a map” as evidence of the uneven playing fields that the ACA would bring in the country and the restrictive options that were increasingly identified with “Obamacare,” as if it were something different from the health policies that increasing numbers of Americans had enrolled in, but rather a specter of higher premiums, fewer rights, and new restrictions on providers if not health policies that could not be trusted, in ways that continued a drumbeat of visualizations predicting coming imbalances for those enrolled in Obamacare to insurance carriers or to a competitive marketplace–if not rob them of access to insurers–concretizing what Donald Trump cannily called “the broken promise” of Obamacare, as some 2.4 million “customers of Obamacare” would be with but one insurer to select in the coming year.   Health officials in the Trump administration issued a “new map showing in full color how many counties in the United States could have zero or just one insurer selling Obamacare health plans in 2018” as if to provide confirmation of the poor deal that was offered the nation; the data vis produced by the folks at the Heritage Foundation was accompanied by an announcement that, in case any one missed the point, insurance exchanges in 2017 would feature ” a major decrease in competition and choice” (italics added) that exposed the deep failure of the ACA to promote competition as promised:

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IB-exchange-competition-2017-map-1-825.gifHeritage Foundation (January 30, 2017)

 

The absence of competition left some state, the not unsubtle point was made, that were neglected by the insurance companies that had promoted the ACA:

 

ACA Header?.png

 

The stark contrasts of the data visualization were a rallying cry for a public campaign for the repeal of the Affordable Care Act, designed to activate the red states that were shown to be the largest losers of the insurance exchanges Obamacare created.  The map released shortly after the inauguration in a push to confirm the repeal of Obamacare, showed almost all counties in the southern United States with but one insurer–as almost a third of the counties in the nation–but not the population by any means.  In the rhetoric of an earlier map that described how “large of swaths of yellow cover a number of Southern and Midwestern states, all of Alaska, and elsewhere indicating counties . . .  are projected as of now to have just one insurer selling individual plans next year,” the images of a restriction of opportunities to buy health insurance was alerted, with areas with but one insurer appropriately colored red, as if to convey danger.

The slightly different visualization from June that accompanied this projected danger suggested that some counties–colored red again–would strip residents enrolled in Obamacare from any insurer for those enrolled in Obamacare–this time in “a new map showing in full color how many counties in the United States could have zero or just one insurer selling Obamacare health plans in 2018“:

 

Conties Analysis ObamacareMSNBC (June 13, 2017)

 

The fear that such maps stoked of an imbalance that cut into the insurance options of many as far as health goes suggested a lack of care and a lack of coverage that suggested a deep disinterest of almost a third of the nation, but did so with little actual grounds.  Those sparsely populated regions loose out in the new marketplace that Obamacare seemed to threaten to impose–even if the Affordable Care Act was created to extend health insurance across the nation:

 

Obamacare 2016_0

McKinsey Center for U.S. Health System Reform (August 26, 2017)

 

Such deep divides within the United States that cut against equal access to health insurance was of course what Obamacare was introduced to prevent, but the exchanges in the less populated states were indeed slow to attract insurers.  However, the terrifying fear of a subtraction of any guarantees of well-being and a level playing field that these projections promote–they are hardly really data visualizations, if they resemble maps–seem as good a definition and a metaphor of undemocratic policies, and a metaphor for the restricted roles people are given a crucial say in the policies and decisions that most affect their lives.  Although the sentiments for including health care as a right has become to a deep divide in the nation, the disadvantages that the initial introduction of the exchanges were cautioned to bring to peoples’ lives and policies were immediately striking.

And the recent success of mapping the actual resurgence of insurers’ involvement in many exchanges in counties nationwide reminds us of–and asks us to reconsider–the deceptive nature of their claims.  Indeed, as recently as June, 2017, media sources presented “a map” or a set of maps as evidence of the imbalances that the previous administration had failed to foresee, or willfully imposed on the nation.

 

1.  The negative benefits to all of health-care being a restrictive good are pretty clearly evident:  healthcare should not be seen as a commodity alone, existing on an open marketplace.  Given the clear negative pressures of lowering access to health care to society, the gleeful prediction by President Trump that Obamacare–as Trump calls the Affordable Care Act (ACA)-, as if it were just not American to promise health care to all–would be implode because of e lack of plans available on exchanges in much of the country thankfully seems untrue.  Indeed, the failure to repeal the ACA by the United States Senate–a failure that seems to have sent a shudder of initial convulsions within the Trump administration, and within Donald J. Trump’s sense of his hold on the Presidency, has led insurers to return to the many counties where they had in previous months left, provided all but one of the counties that seemed to have no clear options in the Obamacare exchanges–and that now-President Trump’s declarations of Obamacare’s demise were quite premature.  Although the graphics of health insurance providers that were available to residents in local exchanges under the Affordable Care Act seemed truly badly served in much of the nation by early 2017–when many of the counties not on the coasts or in coastal states seemed to suffer from a gap in options, as was true even shortly before the 2016 Presidential election in surprisingly effective ways.

As soon as the future markets for insurance were mapped and the maps were released, the revelation of apparent gaps and “dwindling in surname choices” and egregious absences in covering the nation’s populations seemed to show up the falsity of past promises.  The maps gained a polemic authority of their own, confirming lingering suspicions about the poor fit of “Obamacare” to the nation, and providing fodder for raising alarms about the inequitable nature of the exchanges that emerged in different states and counties.  For they seemed to reveal an apparent abandonment of the majority of the country by the coastal elites of California Massachusetts, New York, Chicago and Washington D.C.:  indeed, it triggered a sense of the abandonment of the nation by coastal elites.  The very story that was told about Hillary Clinton and the Democrats in many circles were being repeated in the Presidential campaign were used to lace increasing suspicion about the emergence of fair marketplaces in future years.

 

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County-Level Data on Insurance Providers under ACA/AP  (October, 2016)

 

The deep brown nature of the map didn’t reveal the restrictive choices of insurers, but muddied the picture of the nation, as if throwing into relief a plurality of counties that existed on a higher plateaux of health care, and left behind the rest.  The visualization suggests that a sombre picture of health-care had emerged before the Senate failed to dismantle Obamacare, light tans suggesting the greatest gaps in low-lying lands of few insurance options, and markets where sufficient variability would not bring lower costs.  In those regions, the widespread “lack of choice” appeared so evident in dismaying gaps across the nation, where the departure of insurers from a market seemed that had been seen to rise in 2015 and 2016 had started to fall precipitously, raising the fears of rising premiums.  Several entire states–deep red states, as it happens, like Alabama, South Carolina, Oklahoma, and Wyoming–had only one participating insurer across the entire state, suggesting gaps in the health plan that claimed to be engineered to offer choice.

The mapping of these projections seemed to make manifest the deepest fears of inequality and an unloved playing field, which data visualizations like the above seemed to expose–while dying the projected nature of its claim that insurers’ “departure” had already occurred.  Yet the residents of all counties in the United States but one will be able to purchase an Obamacare plan in the coming year in actuality–the fifth year and enrollment cycle of Obamacare insurance markets, has brought successful expansion, with increasing coverage is provided by insurers across the United States may be even effect a new acceptance of health care as a right.  For despite widely stoked fears of drying out health insurance markets projected in deceptive data visualizations with such particularly alarming effects.

Just a mere two months ago, it was predicted that forty-seven counties would have absolutely no insurers by 2018, and that residents of greater than a thousand counties–and up to 1,200– would be left “bare”–hight and dry–with access to but one insurer in their exchanges.  The alleged analysis of the impending “collapse” of insurer participation nationwide showed an image of “projected insurer participation” as if they described an actuality of declining participation that had effectively fractured the nation–lending currency to pronouncements that struck fear into many voters.

 

County by County analysis.pngExchnage Carrier.pngCNBC, June 13, 2017

 

Despite the manipulative nature of these data visualizations, the recent resilience of markets after election, and specifically the failure to repeal Obamacare, has responded in ways that stand to change.

 

2.  But the picture was indelible when it was framed, forged in the sharp colors of data visualizations which arrived with regularity at the same time as maps of projections of the Presidential election dominated social media and the press.  They created a terrifying image of a divided nation, destroyed by the all but inevitable impending “collapse of Obamacare ‘coverage’ in 2017” as revealed in “stunning maps” released in the late summer during the Presidential election, as if they were the hidden understory of national divisions that some candidates just didn’t get.  These visualizations allegedly revealed divisions of the nation in ways that must have spooked many, weren’t being addressed by the White House or health care officials, and seemed to signal an era’s end–touting “Higher Costs and Fewer Choices for Obamacare Customers in 2017.”  The below-the-radar war of data visualization for national attention suggested nothing less than the erosion of the union that was tied to the encouragement of insurance exchanges.

Such data visualization worked their magic, triggering narratives of abandonment and appearing to reveal an isolation of several of the poorer parts of the nation that set of alarms about the increased division of a nation and an uneven playing field that the Affordable Care Act–now demonized by the name “Obamacare” to distance itself from the actual legislation–that revealed the apparent absence of competition in “stunning” ways.  For by depicting the “epic collapse” of a system that in fact seemed to be give greater stability to a projection and make it manifest as reality.  The magic of the data visualization was that they purported to reveal an actuality the Obama administration seemed to deny as if it were an actuality that denied options to many Americans.   And although the spread of the one-carrier-ounties across much of the “heartland” seemed confirmation, for many Republicans, of an abandonment of the mythic heartland of Trump voters, which pulled from Iowa to New Mexico to West Virginia for Appalachia for Trump–the complexion of where insurance is available.

The alleged objectivity of the visualization left many with breath held, as “stunning maps” released during the heat of the Presidential election in late summer prophesied an impending “collapse of Obamacare ‘coverage’ in 2017” as an all but inevitable reality.

 

Obamacare 2016_0McKinsey Center for U.S. Health System Reform

 

Data visualizations of jarring color selections suggest the discontinuity in a system of health care, using the not necessarily clear metric of the existence of a range of carriers.  The notion of the medical marketplace that such competition was supposed to create however realized clear gaps with the counties in violet, whose disarming continuities suggested pockets of the nation that were unfairly left behind, and others in pink that seemed to be similarly compromised in the notion of options or choice their inhabitants were offered.  But the alarmist cartographies were extremely effective in tellign of a story of those regions that were left out–not only Kansas, but Wyoming, West Virginia, and stretches of North Carolina, South Dakota  and Michigan. The maps spoke to many.

The deeper debate about health care as a right demand to be examined in far greater detail than the polemic nature of such visualizations allowed.  And the recent resurgence of insurers in almost all counties of the nation provides a good occasion to do so.   It’s not a secret that the difficulty of construing health-care as a democratic right has also been rejected by many,–who would  restrict liberties to participation a marketplace.  In doing so, they adopt the market as a primary metaphor if not end of civil society–and view any tampering with the health care market as undue governmental meddling.  Yet the guarantees of well-being and a level playing field seem as good a definition of what is democratic as any, as it affords a needed means to allow people to have greater say in policies and decisions that most affect their lives.  And sentiments for including health care as a right has however come to be one of the deeper divides in the nation.  And the recent success of mapping the real resurgence of insurers’ involvement in many exchanges in counties nationwide reminds us of–and asks us to reconsider–the deceptive nature of their claims about the narrative of the impending collapse of Obamacare that many data visualizations of the nation relentlessly advanced, with minimal questioning or interrogation, and the how the image of the nation they suggest may explain public understandings of health care as a democratic right.

But since the negative benefits to all of health-care being a restrictive good are pretty clearly evident, healthcare should not be seen as a commodity alone, existing on an open marketplace alone.  Given the clear negative pressures of lowering access to health care to society, the gleeful prediction by President Trump that Obamacare–as Trump calls the Affordable Care Act (ACA), as if it were just not American to promise health care to all–would be implode because of e lack of plans available on exchanges in much of the country thankfully seems untrue.  Indeed, the failure to repeal the ACA by the United States Senate–a failure that seems to have sent a shudder of poor guidance and convulsions within the Trump administration, and within Donald J. Trump’s sense of his hold on the Presidency, has led insurers to <em>return</em> to the many counties where they had in previous months left, provided all but one of the counties that seemed to have no clear options in the Obamacare exchanges have gained them.

 

3.  Trump’s declarations of Obamacare’s demise were indeed quite premature.  Although the graphics of health insurance providers that were available to residents in local exchanges under the Affordable Care Act seemed truly badly served in much of the nation by early 2017–when many of the counties not on the coasts or in coastal states seemed to suffer from a gap in available options, as was true even shortly before the 2016 Presidential election in surprisingly effective ways.  The sentiment of a curtailing of options–and of choice, that elusive and so malleable term–became something of a battle-cry against the ACA, which redefined how it was portrayed and cast as an imposition that failed to meet health needs, but whose premiums were substantially more.

If one might say, with poet Elizabeth Bishop, that “more delicate than the historians’ are the mapmaker’s colors,” unlike the color-choices by which cartographers define land and sea as areas viewers can inhabit and read, the stark colors of the data visualization suggest clearcut differences and decisive results–too often just to stark to be lent the credibility that they seek.  Bishop linked the art and science of the cartographer and the art of poetry, in her first published poem, written when staring at a framed map of the North Atlantic that lay under glass as she was ill.  In tracing the mapped waters, and the land that lies beneath the water in maps, shadowed in green, she admired the transformative nature of the cartographer’s art and the expressive license of defining land and sea, and the edges of sandy shelves, as allowing the cartographer to create an aesthetic object able to engage the viewer’s fantasy, through the delicacy of color choices:  the stark, flat tones of the above data visualization–whose colors are all too strict and edges overly severe–work best to create oppositions and manufacture absolutes that offer little distance on the world, or clear purchase on it.

The colors chosen by the cartographer, if at odds with the actuality of the ordering of the land, cannot compare to how the translation of the edges of insured and uninsured are erased in the clear contrasts that compress the actual contours of health care.  If Bishop contrasted the reality claims of the historian to the artifice of the map-maker, whose creations appear arbitrary, but reveal actual complexities, as allowing possibilities for the contemplation of the world.  But rather than presenting an authoritative version of the world, the human measure of a carefully made map, and the invention it offered as an angle at which to examine the world absent from many visualizations, which privilege a single actuality as sufficiently authoritative to orient viewers to the world along a single narrative–and not preserving a human scale to do so.  The deceptive nature with which data visualizations foretold collapsing insurance choices in the Affordable Care Act presented a false reality. about health insurance exchanges, in short, by creating alarming contrasts between sharp colors in maps that offered no opening for interpretation. In contrast, maps of the actual numbers of those without health insurance reveals a landscape of much more complex edges and shadows, as well as deep divides, demanding to be moused over in detail for their interactive experience, if only to come to terms with the changed life experiences of those in many states, as from 2013-16, as the constantly shrinking number of uninsured grew nation wide in ways that attest to the increasing health of the nation–if with considerable numbers of uninsured remaining in may exchanges:

 

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New York Times

 

In contrast, the almost uninhabited landscapes bereft of insurers that data visualizations depict to suggest a narrowing marketplaces and dwindling options of Americans offers an image less about “health”–our about our health as a nation–than the problems of creating continuity among the insurance exchanges that underwrite the insurance marketplace.  The lack of perspective that they offer on the residents of each county and of our country–and the forced viewing of “health” in terms of insurance companies which participate in exchanges, suggest what more contemporary poet, Claudia Rankine, called the particularly contentious meaning of “health” today in the United States:  at a time when “Affordable Care Act” is seen as something different from “Obamacare” by most Americans, who want the affordability of health care but suspect the inequality of “Obamacare”–whose repeal Trump declared his first order of business as President.  “We heard health care and we thought public option/we thought reaching across the street across the lines,/ across the aisle was the manifestation of not a red state/ not a blue state but these united states we thought,” Rankine wrote with assurance of a new landscape of health insurance, “we could be sure of ourselves in this one way sure/of our human element our basic decency.”

But the increased decency of providing more Americans with adequate health care, “a kind of human kind of union we were ready to check-up,” as Rankine wrote, in the belief that “in this one way we were ready/to care for each other we were ready to see/our range of possibilities as a precious commodity,” was distorted in a map that focussed on the marketplaces of insurance options that Obamacare–the Affordable Care Act–sought to create.  If in this nation “despite being founded on genocide and sustained by slavery/in God’s country we thought we were ready/to see sanity inside the humanity,” the humanity of health care seems sadly obscured in the exclusive focus of data visualizations that focus on providers absent from the marketplace.

 

4.  It is rather terrifying that the alleged objectivity and authority of such data visualizations were arrogated to make a point that disguised their nature as projections and roles as arguments.  While doing so is tantamount to disinformation, claiming predictive value as declarative statements which has since proved to be without any merit.  For not only did they distort the question of coverage by ignoring that the areas where three or more carriers would be options were most populated–where the best job had been done informing patients of their options to enroll in policies, and also where far better medical coverage existed for Americans in previous years–but the alarms that they sounded were ungrounded, although the image of two coasts and a well-off midwest that suddenly left large parts of the nation in the lurch effectively tapped into deep suspicions and uncertainty.

Rankine persuasively hypothesized–and elsewhere actively protested–the deeply ingrained racism that motivated a nation ready to distinguish between “Obamacare” and the “Affordable Care Act”–valuing the affordability of health insurance, but suspicious of the insurance labeled by the name of Trump’s predecessor.  The motivations for suspicions about “Obamacare” as a tampering with the free market of health providers is unclear, but it undermines the interest in our understanding of the preciousness of health care as a right.  Yet the humanity of health care seems sadly forgotten by the shift from a topography of individuals insured to a topography of the marketplace.  Although Trump seemed to think he had fired Obamacare from the country by declaring it “dead,” and just destined to implode, the markets revealed themselves to have been set up with considerable resilience, despite deeply troubling glitches in its roll out; if more than eighty counties earlier risked offering no options to enrollees, insurers returned overwhelmingly, where they were able, especially when already strongly present in the marketplaces, despite the threat from President Trump to pull federal subsidies.

The presence of mapping future markets for insurance were released with claims to show of apparent gaps, “dwindling insurance choices,” and egregious absences in covering the nation’s populations.  They seemed to show up the past promises of the President to preserve choices for Americans to adopt a health plan that suit them best, and portray them as undue impositions on the marketplace.  The projections acquired a polemic authority, as if confirming lingering suspicions about the poor fit of “Obamacare” to the nation, by providing fodder for raising alarms about the inequitable nature of exchanges in different counties and even in different states.  They seemed to confirm a feared narrative of the abandonment of the much of the country:  indeed, many popular data visualizations triggered a sense of the abandonment of the nation by coastal elites in New York, California, and Washington DC, in particular in Arizona, Oklahoma, Texas, Colorado, Missouri and the Deep South, as well as parts of Michigan.  They confirmed the very story told about Hillary Clinton and the Democrats repeated in the Presidential campaign as if to lace suspicion about the emergence of fair marketplaces in future years.

 

Graphic-of-Insurance-Providers-number

County-Level Data on Insurance Providers under ACA/AP  (October, 2016)

The particularly grim picture that they offered came in for little criticism or rebuttal.  But the data visualizations describe landscapes that are curiously depopulated, even as they present a sobering picture to suggest the withdrawal of insurers from medical exchanges.   The map implies an absence of interest in much of America by the very insurers who claimed to have sponsored the new marketplaces–but had only concentrated on the most profitable regions.  Its implications one of the abandonment of many of the rural areas of the country–the less densely populated–although the greatest success of such exchanges in densely populated urban areas that were liberal-leaning is no secret, they imply an absence of interest in less populated areas of the nation.  The implicit message that little attention was paid to the rural areas was underlined through the strategic colors of the data visualization, which seems to suggest a relief map of areas that would suffer higher premiums:   audiences in much of the country were convinced that they just had it worse in the projections all too often portrayed as eventualities that the nation would stand to suffer.  The tan colors that suggest diminished choices of medical insurance muddied the picture of the nation, throwing into relief a plurality of counties that existed on a higher plateaux of health care, and left behind the rest.

The visualization suggests that a sombre picture of health-care had emerged before the Senate failed to dismantle Obamacare, light tans suggesting the greatest gaps in low-lying lands of few insurance options, and markets where sufficient variability would not bring lower costs.  In those regions, the widespread “lack of choice” that appeared evident in dismaying gaps across the nation, where the departure of insurers from a market seemed that had been seen to rise in 2015 and 2016 had started to fall precipitously, raising the fears of rising premiums.  Several entire states–deep red states, as it happens, like Alabama, South Carolina, Oklahoma, and Wyoming–had only one participating insurer across the entire state, suggesting gaps in the health plan that claimed to be engineered to offer choice.

Such premature projections seemed to make manifest the deepest fears of inequality and an unloved playing field, and invested themselves with an objective authority of exposing an uneven system that was indeed rigged–denying the projected nature of its claim that insurers’ “departure” had already occurred.  Yet residents of all counties in the United States but one will in fact be able to purchase an Obamacare plan in the coming year in actuality–the fifth year and enrollment cycle of Obamacare insurance markets, has brought successful expansion, with increasing coverage is provided by insurers across the United States may be even effect acceptance of health care as a right.  For despite widely stoked fears of drying out health insurance markets projected in deceptive data visualizations with such particularly alarming effects.

 

2.  To better grapple with the readiness of insurers to fill the health-care marketplace, the stunning maps of the presence of insurers who have made health-care policies available demands to be examined through a red state-blue state optic.  For eve if the aversion of Republican-leaning regions in the United States to providing alternatives to health care insurers creates a deep divide concentrated in much of the south, prairie, and southwest, where only 1-2 insurers exist, and despite uneven nature of conditions conducive to access to health services that guarantee well-being–and presumably happiness–the markets have grown.

 

HEalth Care Insureres:Red v Blue Govs.png

 

 

If the divide looks harsh anyway for many rural areas, the red/blue divides cannot reflect the actual availability of health providers to Americans.  Since the notion of the division of the distribution of insurance markets by counties seemed suspect anyway, given the sparser population of many of these states, a more accurate picture of national coverage is offered by a simple proportional warping of the odd division of the electorate by the “county”–an outdated geographical unit if there ever was one.  The mapped that warped counties by their relative populations reveals  an even sharper picture of the actually improving state of availability of insurers–the fewer residents of many of the just-one-insurer regions of the south and indeed midwest shrink, to confirm the growing success of the selection of insurance providers by the ACA, despite some obviously problematic and important to address gaps in coverage.

 

Warped Map on Insurers Red v Blue Goves.png

 

It is striking that these very gaps mirror with a terrifyingly clear correlation both dial-up speeds and broadband technology, as well as intractable bottom-line problems like gaps in the availability of health-care services in rural areas.

 

FQHCs.png

 

federally-qualified-health-centers

Rural Health Information Hub, December 2016

 

 

5.  Abandoning the red/blue divisions, which are taken by the elected governor, we see an even healthier division of the nation, at least in terms of the regions that provide their residents with something like a reasonable variety of possible health care insurers, with large areas of the most populated areas having three potential insurers, rather than insurance markets imploding at all, despite the clear gaps that it reveals in what seem more underpopulated areas–and, quite strikingly, the absence of broadband that would make it easier to enroll for insurance online.

 

5995cec01400001f002c3494Harold Pollack and Todd Stubble

 

Broadband 2014.pngNational Broadband Map, June 2014 (not updated since)

 

These gaps reveal a division of much of America into two regions–no doubt conducive between two expectations of health care or medical provision.  Most southern states indeed had far fewer insurers–left “bare” with but one provider, despite the low populations of such rural regions being just less conducive to insurance markets, and revealing an uneven playing field long preceding the passage of the Affordable Care Act–

 

SOUTHERN states health care insurers 2017-18Harold Pollack/HealthInsurance.org

 

One Provider South Rural.pngHarold Pollack and Todd Schuble

 

The area is not only medically underserved, but suggests a “Southern Problem” having far less to do with Obamacare than with the disproportionate topography of medicine and indeed of those without health-care, but creating many counties including large stretches of chronic undeserved populations.

 

RAC 2014

 

 

Such maps and data visualizations only suggest a need to appreciate and fathom the deeply compromised liberties in areas with few health insurance providers, where insurers haven’t reached clear markets, that not only overlap with many of the more chronically uninsured areas and populations, but with areas of the a terrifying number of uninsured–folks who have decided or been forced to do without health insurance, and where going without health insurance becomes an accepted acceptable alternative, unlike in many regions of the country,

 

 

us-health-insurance-coverage-map

 

which often echoed the very regions of greatest vulnerability in the nation–counties that to be sure often reached out to Trump as a savior for their deep discontent.

 

Rural Assistance Center Underserved.png

 

RAC 2014.png

 

 

2.  The increasing variety of insurance options for much of the nation raises questions about the persistence of a deep inequality–undemocratic for many–in those pockets coinciding with denser votes for Trump, in a normalized choropleth, and more hospitable to an argument of revising current options of health care–and viewing the Affordable Care Act as an imposition of the federal government.

 

Trump votes normalized choropleth

 

There are interesting overlaps on those areas where Trump out-performed previous Republican candidates, notably in Florida’s panhandle and less densely populous counties in the deep south; southern Texas; and Appalachia.

 

trump-increases-republican-votes

 

 

The odd reluctance of these areas to attract anything like a range of possible insurers in lower income areas of low-density where Republicans have recently performed well.

 

counties-1

New York Times

 

trumpland-2.png

They reflect the difficult problem of distinct notions of liberty and rights in the country, corresponding to areas where the civilian population was long underinsured, often by upwards of 15%, and where shortages of health-providers–even if not as readily available in county-level data–are strikingly revealed in a state-by-state survey:  states like Georgia, Mississippi, Arkansas, New Mexico, Nevada and Texas remained significantly below the national average for primary care physicians in 2012, suggesting regions where there were less developed expectations for attaining health care coverage.

 

maptitude-healthcare-providers-by-state-map.jpg

 

 

Increased numbers of uninsured exist in many of the same states are, to recap, unsurprisingly located in some of the same regions–which are less likely to vote for representatives who advocate the belief in health care as a right, and perhaps seeing it as able to be outweighed in importance by an argument of states’ “rights,” even if this discourse is designed to deny health insurance.

 

us-health-insurance-coverage-map.jpg

 

It seems a cruel irony in an era of globalization that the majority of those doctors or members of the healthcare force serving areas of the United States that were most in need, and who see some 14 millions patients every year, were from Iran, Libya, Somalia, Sudan, Syria, or Yemen–citizens of countries included in Trump’s Muslim Ban.  (In other words, these immigrant doctors are filling the increasingly pronounced gap that exists among medical providers in the United States–and getting the job done.)  If medically underserved areas occur in almost every state in the country, the preponderance of medically underserved populations concentrated in less populated areas–as the southwest, southern states, and parts of the Midwest seems to have attracted foreign doctors–and had already led bills to be sponsored to allow Medicare to reimburse pharmacists directly in those communities, to acknowledge the absence of medical services needed by Medicare beneficiaries, to allow clinical pharmacists to work in medical care settings as a health provider.

 

Doctors from coutnries in Muslim Ban.pngSee interactive version of this map here, at the Immigrant Doctors Project

 

The map has some striking overlaps with those regions of rural America that are losing population, although it should be kept tin mind that the above map, which used data from Doximity to suggest the commenting zones for the number of doctors in the United States may distort by expanding the zones of providing services beyond that which physicians actually serve most actively:

:

map-loss.pngRural Communities Losing Populations, United States of America

 

The elevation of the pharmacist to a medical provider may raise ethical questions.  But the existence of hight concentrations of medical physicians from the very countries that were targeted by the so-called “Muslim Ban” that Trump championed had the effect of allowing a crucial degree of medical assistance to reach Americans–although the apparent intent of Trump’s legislation would have been to restrict their abilities to return home freely to visit their families, and compromise the proportion of doctors on call in the cities where they are most concentrated–in Toledo, Cleveland, and Dayton, Ohio as well as Detroit MI.

 

Medical Assistance.pngImmigrant Doctors Project

 

Such pronounced concentrations of physicians which were mapped online in readily seaarchable formats by the Immigrant Doctors Project provide powerful tools to view how the markets for physicians’ skills meets the needs of a marketplace, to be sure, if one recalls the huge numbers of medically underserved counties.  But this is not a marketplace that would be easily filled by our current medical system, or the health-care industries that service more rural or poorer areas.

 

RAC 2014.png

 

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Filed under Affordable Care Act, data visualization, health care, health insurance, Obamacare

Mapping Bannon’s Ban

American President Donald Trump claimed that his attempt to prevent visitors from seven countries entering the United States preserved Americans’ safety against what was crudely mapped as “Islamic terror” to “keep our country safe.”  Trump has made no bones as a candidate in calling for a “total and complete shutdown of Muslims” as among his most important priorities if elected President.  The map the he has asked the nation to draw about who can enter the country–purportedly because they are “terrorist-prone” nations–a bizarre shorthand for countries unable to protect the United States from terrorism–as if this would guarantee greater safety within the United States.  For as the Department of Homeland Security  affirmed a need to thwart terrorist or criminal infiltration by foreign nationals, citing the porous borders of a country possessing “the world’s most generous immigration system” that has been “repeatedly exploited by malicious actors,” and located the dangers of terror threats from outside the country as a subject for national concern, provoking anxiety by its demonization of other states as national threats.  And even though the eagerly anticipated “ban” lacks “any credible national security rationale” as governmental policy, given the problem of linking the radicalization of any foreign-born terrorist or extremists were only radicalized or identified as terrorists after having become Americans, country of citizenship seems an extremely poor prognostic or indicator of who is to be considered a national danger.

Such eager mapping of threats from lands unable to police emigration to the United States oddly recall Cold War fears of “globally coordinated propaganda program” Communist Parties posing “unremitting use of propaganda as an instrument for the propagation of Marxist-Leninist ideology” once affirmed with omniscience in works as Worldwide Communist Propaganda Activities.  Much as such works invited fears for the scale and scope of Communist propaganda “in all parts of the world,” however, the executive order focusses on our own borders and the borders of selective countries in the new “Middle East” of the post-9/11 era. The imagined mandate to guard our borders in the new administration has created a new eagerness to map danger definitively, out of deep frustration at the difficulty with which non-state actors could be mapped.  While allegedly targeting nations whose citizens are mostly of Muslim faith, the ban conceals its lack of foundations and unsubstantiated half-truths.

The renewal of the ban against all citizens of six countries–altered slightly from the first version of the ban in hopes it would successfully pass judicial review, claims to prevent “foreign terrorist entry” without necessary proof of the links.  The ban seems intended to inspire fear in a far more broad geography, as much as it provides a refined tool based on separate knowledge.  Most importantly, perhaps, it is rigidly two-dimensional, ignoring the fact that terrorist organizations no longer respect national frontiers, and misconstruing the threat of non-state actors.  How could such a map of fixed frontiers come to be presented a plausible or considered response to a terrorist threats from non-state actors?

 

travel-ban-trump

 

1. The travel ba focus on “Islamic majority states” was raised immediately after it was unveiled and discourse on the ban and its legality dominated the television broadcasting and online news.  The suspicions opened by the arrival from Wall Street Journal editor-in-chief Gerard Baker that his writers drop the term “‘seven majority-Muslim countries'” due to its “very loaded” nature prompted a quick evaluation of the relation of religion to the ban that the Trump administration chose at its opening salvo in redirecting the United States presidency in the Trump era.  Baker’s requested his paper’s editors to acknowledge the limited value of the phrase as grounds to drop “exclusive use” of the phrase to refer to the executive order on immigration, as if to whitewash the clear manner in which it mapped terrorist threats; Baker soon claimed he allegedly intended “no ban on the phrase ‘Muslim-majority country’” before considerable opposition among his staff writers–but rather only to question its descriptive value. Yet given evidence that Trump sought a legal basis for implementing a ‘Muslim Ban’ and the assertion of Trump’s adviser Stephen Miller that the revised language of the ban might achieve the “same basic policy outcome” of excluding Muslim immigrants from entering the country.  But curtailing of the macro “Muslim majority” concealed the blatant targeting of Muslims by the ban, which incriminated the citizens of seven countries by association, without evidence of ties to known terror groups.

The devaluation of the language of religious targeting in Baker’s bald-faced plea–“Can we stop saying ‘seven majority Muslim countries’? It’s very loaded”–seemed design to disguise a lack of appreciation for national religious diversity in the United States. “The reason they’ve been chosen is not because they’re majority Muslim but because they’re on the list of countRies [sic] Obama identified as countries of concern,” Baker opined, hoping it would be “less loaded to say ‘seven countries the US has designated as being states that pose significant or elevated risks of terrorism,'” but obscuring the targeting and replicating Trump’s own justification of the ban–even as other news media characterized the order as a “Muslim ban,” and as directed to all residents of Muslim-Majority countries.  The reluctance to clarify the scope of the executive order on immigration seems to have disguised the United States’ government’s reluctance to recognize the nation’s religious plurality, and unconstitutionality of grouping one faith, race, creed, or other group as possessing lesser rights.

It is necessary to excavate the sort of oppositions used to justify this imagined geography and the very steep claims about who can enter and cross our national frontiers.  To understand the dangers that this two-dimensional map propugns, it is important to examine the doctrines that it seeks to vindicate.  For irrespective of its alleged origins, the map that intended to ban entrance of those nations accused without proof of being terrorists or from “terror-prone” nations.   The “Executive Order Protecting the Nation from Foreign Terrorist Entry into the United States,” defended as a legal extension of the President’s “rightful authority to keep our people safe,” purported to respond to a crisis in national security.  The recent expansion of this mandate to “keep our people safe” against alleged immanent threats has focused on the right to bring laptops on planes without storing them in their baggage, forcing visitors form some nations to buy a computer from a Best Buy vending machine of the sort located in airport kiosks from Dubai to Abu Dhabi, on the grounds that this would lend greater security to the nation.

 

2.  Its sense of urgency should not obscure the ability to excavate the simplified binaries that  justify its imagined geography.  For the ban uses broad brushstrokes to define who can enter and cross our national frontiers that seek to control discourse on terrorist danger as only a map is able to do.  To understand the dangers that this two-dimensional map proposes, one must begin from examining the unstated doctrines that it seeks to vindicate:  irrespective of its alleged origins, the map that intended to ban entrance of those nations accused without proof of being terrorists or from “terror-prone” nations.   The “Executive Order Protecting the Nation from Foreign Terrorist Entry into the United States,” defended as a legal extension of the President’s “rightful authority to keep our people safe,” purported to respond to a crisis in national security.  The recent expansion of this mandate to “keep our people safe” against alleged immanent threats has focused on the right to bring laptops on planes without storing them in their baggage, on the largeely unsubstantiated grounds that this would lend greater security to the nation.

The lack of compunction to attend to the religious plurality of the United States citizens bizarrely date such a purported Ban, which reveals a spatial imaginary that run against Constitutional norms.  In ways that recall exclusionary laws based on race or national origin from the early twentieth century legal system, or racial quotas Congress enacted in 1965, the ban raises constitutional questions with a moral outrage compounded as many of the nations cited–Syria; Sudan; Somalia; Iran–are sites from refugees fleeing Westward or transit countries, according to Human Rights Watch, or transit sites, as Libya.  The addition to that list of a nation, Yemen, whose citizens were intensively bombed by the United States Navy Seals and United States Marine drones in a blitz of greater intensity than recent years suggests particular recklessness in bringing instability to a region’s citizens while banning its refugees.  Even in a continued war against non-state actors as al Qaeda or AQAP–al Qaeda in the Arabian Peninsula–the map of Trump’s long-promised “Islamic Ban” holds sovereign boundaries trump human rights or humanitarian needs.

The ban as it is mapped defines “terror-prone regions” identified by the United States will only feed and recycle narratives of western persecution  that can only perpetuate the urgency of calls for Jihad.  Insisting national responsibility preventing admission of national citizens of these beleaguered nations placed a premium on protecting United States sovereignty and creates a mental map that removes the United States for responsibility of military actions, unproductively and unwarrantedly demonizing the nations as a seat of terrorist activity, and over-riding pressing issues of human rights tied to a global refugee crisis.  But the mapping of a ban on “Foreign Terrorist Entry” into the United States seems to be something of a dramaturgical device to allege an imagined geography of where the “bad guys” live–even a retrograde 2-D map, hopelessly antiquated in an age of data maps of flows, trafficking, and population growth, provides a reductive way to imagine averting an impending threat of terror–and not to contain a foreign threat of non-state actors who don’t live in clearly defined bounds or have citizenship.  Despite an absolute lack of proof or evidence of exclusion save probable religion–or insufficient vetting practices in foreign countries–seems to make a threat real to the United States and to magnify that threat for an audience, oblivious to its real effects.

For whereas once threats of terror were imagined as residing within the United States from radicalized regions where anti-war protests had occurred,  focussed on Northern California, Los Angeles, Chicago, and the northeastern seaboard and elite universities–and a geography of home-grown guerrilla acts undermining governmental authority and destabilizing the state by local actions designed to inspire a revolutionary “state of mind,” which the map both reduced to the nation’s margins of politicized enclaves, but presented as an indigenous danger of cumulatively destabilizing society, inspired by the proposition of entirely homegrown agitation against the status quo:

 

 

Guerilla acts of Sabotage and Terrorism in US

 

Unlike the notion of terrorism as a tactic in campaigns of subversion and interference modeled after a revolutionary movement within the nation, the executive order located demons of terror outside the United States, if lying in terrifying proximity to its borders.  The external threats call for ensuring that “those entering this country will not harm the American people after entering, and that they do not bear malicious intent toward the United States and its people” fabricate magnified dangers by mapping its location abroad.

 

2.  The Trump administration has asserted a need for immediate protection of the nation, although none were ever provided in the executive order.  The  arrogance of the travel ban appears to make due on heatrical campaign promises for “a complete and total ban” on Muslims entering the United States without justification on any legitimate objective grounds.  Such a map of “foreign terrorists” was most probably made for Trump’s supporters, without much thought about its international consequences or audience, incredible as this might sound, to create a sense of identity and have the appearance of taking clear action against America’s enemies.  The assertion that “we only want to admit people into our country who will support our country, and love–deeply–our people” suggested not only a logic of America First, but seemed to speak only to his home base, and talking less as a Presidential leader than an ideologue who sought to defend the security of national boundaries for Americans as if they were under attack.  Such a verbal and conceptual map in other words does immense work in asserting the right of the state to separate friends from enemies, and demonize the members of nations that it asserts to be tied to or unable to vet the arrival of terrorists.

The map sent many scrambling to find a basis in geographical logic, and indeed to remap the effects of the ban, if only to process its effects better.

 

travel-ban-trump

 

But the broad scope of the ban which seems as if it will have the greatest effect in alienating other nations and undermining our foreign policy, as it perpetuates a belief in an opposition between Islam and the United States that is both alarming and disorienting.  The defense was made without justifying the claims that he made for the links of their citizens to terror–save the quite cryptic warning that “our enemies often use our own freedoms and generosity against us”–presumes that the greatest risks not only come from outside our nation, but are rooted in foreign Islamic states, even as we have been engaged for the past decade in a struggle against non-state actors.  In contrast to such ungratefulness, Trump had repeatedly promised in his campaign to end definitively all “immigration from terror-prone regions, where vetting cannot safely occur,” after he had been criticized for calling during the election for “a total and complete shutdown of Muslims entering the United States” until they could “figure out what is going on.”

But the targeted audience was always there, and few of his supporters were likely to have forgotten the earlier claims–and the origins of this geographical classification of national enemies terrifying that offers such a clear dichotomy along national lines.  While pushed to its logical conclusion, the ban on travel could be extended to the range of seventy-odd nations that include a ban against nations associated with terrorism or extremist activity–

 

totalcountriesensnaredintrumpproposals_ea1d4e4541c1a7fc9ec0d213f172e67e.nbcnews-ux-600-480Nick Kiray/NBC News

 

–but there is a danger in attributing any sense of logical coherence to Trump’s executive order in its claims or even in its intent.  The President’s increasing insistence on his ability to instate an “extreme vetting” process–which we do not yet fully understand–seems a bravado mapping of danger, with less eye to the consequences on the world or on how America will be seen by Middle Eastern nations, or in a court of law.  The map is more of a gesture, a provocation, and an assertion of American privilege that oddly ignores the proven pathways of the spread of terrorism or its sociological study.

But by using a broad generalization of foreign nations as not trustworthy in their ability to protect American interests to contain “foreign terrorists”–a coded generalization if there ever was one–Trump remapped the relation of the United States to much of the world in ways that will be difficult to change.  For in vastly expanding the category “foreign terrorists” to the citizens of a group of Muslim-majority nations, he conceals that few living in those countries are indeed terrorists–and suggests that he hardly cares.  The executive order claims to map a range of dangers present to our state not previously recognized in sufficient or honest ways, but maps those states in need as sites of national danger–an actual crisis in national security  he has somehow detected in his status as President–that conceal the very sort of non-state actors–from ISIS to al-Qaeda–that have targeted the United States in recent years.  By enacting a promised “complete and total ban” on the entry of Muslims from entering the nation sets a very dangerous precedent for excluding people from our shores.  The targeting of six nations almost exemplifies a form of retributive justice against nations exploited as seats of terrorist organizations, to foment a Manichean animosity between majority Muslim states and the United States–“you’re either with us, or you’re against us”–that hardly passes as a foreign  policy map.

Rather than respecting or prioritizing human rights, the identification of Islam with terrorist organizations seems the basis for excluding citizens and nationals of seven nations who might allow “foreign terrorist entry.”   The ban was quickly noted that the list of nations pointedly excluded those where Trump did or pursued business as a businessman and hotelier.  But while not acknowledging this distinction, it promotes a difference between “friend” and “enemy” as a remapping of threats to the nation along national lines, targeting nations not only as suspicious sites of radicalization, but by collectively prohibiting their residents and nationals from entry to the nation.  While it is striking that President Jimmy Carter had targeted similar states identified as the nations that “have repeatedly provided support for acts of international terrorism” back in 1980–President Carter cited the long-unstable nations of  Iraq, Libya, South Yemen, and Syria, following then-recent legislation indicating their abilities “support acts of international terrorism.”  The near-identical mapping of terror does not exemplify an egregious instance of “mission creep,” but by blanketing of such foreign nationals as “inadmissible  aliens” without evidence save “protecting the homeland” suggests an unimaginable level of xenophobia–toxic to foreign relations, and to anyone interested in defending national security.  It may Israeli or Middle Eastern intelligence poorly mapped the spread of growing dangers.

But it echoes strikingly similar historical claims to defend national security interests have long disguised the targeting of groups, and have deep Cold War origins, long tied to preventing entrance of aliens with dangerous opinions, associations or beliefs.  It’s telling that attorneys generals in Hawai’i and California first challenged the revised executive order–where memories survives of notorious Presidential executive order 9006, which so divisively relocated over 110,000 Japanese Americans to remote areas, the Asian Exclusion Act, and late nineteenth-century Chinese Exclusion Act, which limited immigration, as the Act similarly selectively targets select Americans by blocking in unduly onerous ways overseas families of co-nationals from entering the country, and establishes a precedent for open intolerance of the targeting the Muslims as “foreign terrorists” in the absence of any proof.

The “map” by which Trump insists that “malevolent actors” in nations with problems of terrorism be kept out for reasons of national security mismaps terrorism, and posits a false distinction among nation states, but projects a terrorist identity onto states which  Trump’s supporters can take satisfaction in recognizing, and delivers on the promise that Trump had long ago made–in his very first televised advertisements to air on television–to his constituents.

 

trump-ban-on-muslimsfrom Donald Trump’s First Campaign Ad (2016)

Such claims have been transmuted, to members of a religion in ways that suggest a new twist on a geography of terror around Islam, and the Trump’s bogeyman of “Islamic terror.” Although high courts have rescinded the first version of the bill, the obstinance of Trump’s attempt to map dangers to America suggests a mindset frozen in an altogether antiquated notion of national enemies.  Much in the way that Cold War governments prevented Americans from travel abroad for reasons of “national security,” the rationale for allowing groups advocating or engaging in terrorist acts–including citizens of the countries mapped in red, as if to highlight their danger, below–extend to a menace of international terrorism now linked in extremely broad-brushed terms to the religion of Islam–albeit with the notable exceptions of those nations with which the Trump family has conducted business.

Bloomberg

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The targeting of such nations is almost an example of retributive justice for having been used as seats of terrorist organizations, but almost seek to foment a Manichean animosity between majority Muslim states and the United States, and identify Islam with terror–  “you’re either with us, or you’re against us“–that hardly passes as a foreign  policy map.  The map of the ban offers an argument from sovereignty that overrides one of human rights.

 

3.  It should escape no one that the Executive Order on Immigration parallels a contraction of  the provision of information from intelligence officials to the President that assigns filtering roles of new heights to Presidential advisors to create or fashion narratives:   for as advisers are charged to distill global conflicts to the dimensions of a page, double-spaced and with all relevant figures, such briefings at the President’s request give special prominence to reducing conflicts to the dimensions of a single map.   Distilled Daily Briefings are by no means fixed, and evolve to fit situations, varying in length considerably in recent years accordance to administrations’ styles.  But one might rightly worry about the shortened length by which recent PDB’s provide a means for the intelligence community to adequately inform a sitting President:  Trump’s President’s Daily Briefing reduce security threats around the entire globe to one page, including charts, assigning a prominent place to maps likely to distort images of the dangers of Islam and perpetuated preconceptions, as those which provide guidelines for Border Control.

In an increasingly illiberal state, where the government is seen less as a defender of rights than as protecting American interests, maps offer powerful roles of asserting the integrity of the nation-state against foreign dangers, even if the terrorist organizations that the United States has tired to contain are transnational in nature and character.  For maps offer particularly sensitive registers of preoccupations, and effective ways to embody fears.  They offer the power to create an immediate sense of territorial presence within a map serves well accentuate divides.  And the provision of a map to define how the Muslim Ban provides a from seven–or from six–countries is presented as a tool to “protect the American people” and “protecting the nation from foreign terrorist entry into the United States” offers an image targeting countries who allegedly pose dangers to the United States, in ways that embody the notion.  “The majority of people convicted in our courts for terrorism-related offenses came from abroad,” the nation was seemed to capitalize on their poor notions of geography, as the President provided map of nations from which terrorists originate, strikingly targeting Muslim-majority nations “to protect the American people.”

Yet is the current ban, even if exempting visa holders from these nations, offers no means of considering rights of entry to the United States, classifying all foreigners from these nations as potential “foreign terrorists” free from any actual proof.

 

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Is such an open expenditure of the capital of memories of some fifteen years past of 9/11 still enough to enforce this executive order on the nebulous grounds of national safety?  Even if Iraqi officials seem to have breathed a sigh of relief at being removed from Muslim Ban 2.0, the Manichean tendencies that underly both executive orders are feared to foster opposition to the United States in a politically unstable region, and deeply ignores the multi-national nature of terrorist groups that Trump seems to refuse to see as non-state actors, and omits the dangers posed by other countries known to house active terrorist cells.  In ways that aim to take our eyes off of the refugee crisis that is so prominently afflicting the world, Trump’s ban indeed turns attention from the stateless to the citizens of predominantly Muslim nation, limiting attention to displaced persons or refugees from countries whose social fabric is torn by civil wars, in the name of national self-interest, in an open attempt to remap the place of the United States in the world by protecting it from external chaos.

The map covered the absence of any clear basis for its geographical concentration,  asserting that these nations have “lost control” over battles against terrorism and force the United States to provide a “responsible . . . screening” of since people admitted from such countries “may belong to terrorist groups. ” Attorney General Jeff Sessions struggled to rationalize its indiscriminate range, as the nations “lost control” over terrorist groups or sponsored them.  The map made to describe the seven Muslim-majority nations whose citizens will be vetted before entering the United States.  As the original Ban immediately conjured a map by targeting seven nations, in ways that made its assertions a pressing reality, the insistence on the six-nation ban as a lawful and responsible extension of executive authority as a decision of national security, but asked the public only to trust the extensive information that the President has had access to before the decree, but listed to real reasons for its map.  The maps were employed, in a circular sort of logic, to offer evidence for the imperative to recognize the dangers that their citizens might pose to our national security as a way to keep our own borders safe.  The justification of the second iteration of the Ban that “each of these countries is a state sponsor of terrorism, has been significantly compromised by terrorist organizations, or contains active conflict zones” stays conveniently silent about the broad range of ongoing global conflicts in the same regions–

Conflict-Map-2015-480x270.jpgArmed Conflict Survey, 2015

–or the real index of terrorist threats, according to the Global Terrorism Index (GTI), compiled by the Institute for Economics and Peace

18855940_401.png Institute for Economics and Peace

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–but give a comforting notion that we can in fact “map” terrorism in a responsible way, and that the previous administration failed to do so in a responsible way.  With instability only bound to increase in 2017, especially in the Middle East and north Africa, the focus on seven or six countries whose populace is predominantly Muslim seems a distraction from the range of recent terrorist attacks across a broad range of nations, many of which are theaters of war that have been bombed by the United States.

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The notion of “keeping our borders safe from terrorism” was the subtext of the map, which was itself a means to make the nation safe as “threats to our security evolve and change,” and the need to “keep terrorists from entering our country.”  For its argument foregrounds sovereignty and obscures human rights, leading us to ban refugees from the very same lands–Yemen–that we also bomb.

For the map in the header to this post focus attention on the dangers posed by populations of seven predominantly Muslim nations declared to pose to our nation’s safety that echo Trump’s own harping on “radical Islamic terrorist activities” in the course of the Presidential campaign.  By linking states with “terrorist groups” such as ISIS (Syria; Libya), al-Qaeda (Iran; Somalia), Hezbollah (Sudan; Syria), and AQAP (Yemen), that have “porous borders”–a term applied to both Libya, Sudan and Yemen, but also applies to Syria and Iran, whose governments are cast as “state sponsors” of terrorism–the executive orders reminds readers of our own borders, and their dangers of infiltration, as if terrorism is an entity outside of our nation.  That the states mentioned in the “ban” are among the poorest and most isolated in the region is hardly something for which to punish their citizens, or to use to create greater regional stability.  (The citation in Trump’s new executive order of the example of a “native of Somalia who had been brought to the United States as a child refugee and later became a naturalized United States citizen sentenced to thirty years [for] . . .  attempting to use a weapon of mass destruction as part of a plot to detonate a bomb at a crowded Christmas-tree-lighting ceremony” emphasizes the religious nature of this threats that warrant such a 90-day suspension of these nationals whose entrance could be judged “detrimental to the interests of the United States.”)

4.  It’s not coincidental that soon after we quite suddenly learned about President Trump’s decision to ban citizens or refugees from seven Muslim-majority countries before the executive order on immigration and refugees would released, or could be read, maps appeared on the nightly news–notably, on both FOX and CNN–that described the ban as a fait accompli, as if to deny the possibility of resistance to a travel prohibition that had been devised by members of the executive without consultation of law makers, Trump’s own Department of State, or the judiciary.   The map affirmed a spatial divide removed from judicial review. Indeed, framing the Muslim Ban in a map not that tacitly reminds us of the borders of our own nation, their protection, and the deep-lying threat of border control.  Although, of course, the collective mapping of nations whose citizens are classified en masse as threats to our national safety offers an illusion of national security, removed from the actual paths terrorists have taken in attacks plotted in the years since 9/11–

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–or the removal of the prime theater of terrorist attacks from the United States since 9/11.  The specter of terror haunting the nation ignores the actual distribution of Al Qaeda affiliates cells or of ISIS, let alone the broad dissemination of terrorist causes on social media.

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For in creating a false sense of containment, the Ban performs of a reassuring cartography of danger for Trump’s constituents, resting on an image of collective safety–rather than actual dangers.  The Ban rests on a conception of executive privilege nurtured in Trump’s cabinet that derived from an expanded sense of the scope of executive powers, but it may however provide an unprecedented remapping the international relations of the United States in the post-9/11 era; it immediately located dangers to the Republic outside its borders in what it maps as the Islamic world, that may draw more of its validity as much from the geopolitical vision of the American political scientist Samuel P. Huntington as it reflects current reality, and it offers an unclear map of where terror threats exist.  In the manner that many early modern printed maps placed monsters at what were seen as the borders of the inhabited world, the Islamic Ban maps “enemies of the state” on  the borders of Western Civilization–and on what it sees as the most unstable borders of the larger “Muslim world”–

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–as much as those nations with ISIL affiliates, who have spread far beyond any country.

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But by playing the issue as one of nations that are responsible for maintaining their own borders, Trump has cast the issue of terrorism as one of border security, in ways perhaps close to his liking, and which plays to his constituency’s ideas of defending America, but far removed from any sense of the international networks of terror, or of the communications among them.  Indeed, the six- or seven-nation map that has been proposed in the Muslim Ban and its lightly reworked second version, Ban 2.0, suggest that terrorism is an easily identifiable export, that respect state lines, while the range of fighters present in Syria and Iraq suggest the unprecedented global breadth that these conflicts have won, extending to Indonesia and Malaysia, through the wide-ranging propaganda machine of the Islamic State, which makes it irresponsibly outdated to think about sovereign divisions and lines as a way for “defending the nation.”

18980564_401Deutsche Welle/2016

Trump rolled out the proposal with a flourish in his visit to the Pentagon, no doubt relishing the photo op at a podium in the center of military power on which he had set his eyes.  No doubt this was intentended.  For Trump regards the Ban as a “border security” issue,  based on an idea of criminalizing border crossing that he sees as an act of defending national safety, as a promise made to the American people during his Presidential campaign.  As much as undertake to protect the nation from an actual threat, it created an image of danger that confirmed the deepest hunches of Trump, Bannon, and Miller.  For in  ways that set the stage for deporting illegal immigrants by thousands of newly-hired border agents, the massive remapping of who was legally allowed to enter the United States–together with the suspension of the rights of those applying for visas as tourists or workers, or for refugee status–eliminated the concept of according any rights for immigrants or refugees from seven Muslim-majority countries on the basis of the danger that they allegedly collectively constituted to the United States.  The rubric of “enhancing public safety within the interior United States” is based on a new way of mapping the power of government to collectively stigmatize and deny rights to a large section of the world, and separate the United States from previous human rights accords.

It has escaped the notice of few that the extra-governmental channels of communication Trump preferred as a candidate and is privileging in his attacks on the media indicates his preference for operating outside established channels–in ways which dangerously to appeal to the nation to explain the imminent vulnerabilities to the nation from afar.  Trump has regularly claimed to undertake “the most substantial border security measures in a generation to keep our nation and our tax dollars safe” in a speech made “directly to the American people,” as if outside a governmental apparatus or legislative review.  And while claiming to have begun “the most substantial border security measures in a generation to keep our nation and our tax dollars safe” in speeches made “directly to the american people with the media present, . . . because many of our reporters . . . will not tell you the truth,” he seems to relish the declaration of an expansion of policies to police entrance to the country, treating the nation as if an expensive nightclub or exclusive resort, where he can determine access by policies outside a governmental apparatus or legislative review.   Even after the unanimous questioning by an appellate court of the constitutionality of the executive order issued to bar both refugees and citizens of seven Muslim-majority nations, Trump insists he is still keeping every option open and on the verge this coming week of just filing a brand new order designed to leave more families in legal limbo and refugees safely outside of the United States.  The result has been to send waves of fear among refugees already in the Untied States about their future security, and among refugees in camps across the Middle East.  The new order–which exempts visa holders from the nations, as well as green card holders, and does not target Syrian refugees when processing visas–nonetheless is directed to the identical seven countries, Iran, Iraq, Syria, Yemen, Somalia, Sudan and Libya, while retaining a policy of or capping the number of refugees granted citizenship or immigrant status, taking advantage of a linguistic slippage between the recognition of their refugee status and the designation as refugees of those fleeing their home countries.

 

While the revised Executive Order seems to restore the proposed ceiling of 50,000 refugees chosen in 1980 for those fleeing political chaos with “well-founded fears of persecution,” the new policy, unlike the Refugee Act of 1980, makes no attempt to provide a flexible mechanism to take account of growing global refugee problems even as it greatly exaggerates the dangers refugees admitted to America pose, and inspires fear in an increasingly vulnerable population of displaced peoples.

 

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For Trump’s original Executive Order on Immigration rather openly blocks entry to the country in ways that reorient the relation of the United States to the world.  It disturbingly remaps our national policy of international humanitarianism, placing a premium on our relation to terrorist organizations:   at a stroke, and without consultation with our allies, it closes our borders to foreign entry to all visa holders or refugees in something more tantamount to a quarantine of the sort that Donald Trump advocated in response to the eruption of infections from Ebola than to a credible security measure.  The fear of attack is underscored in the order.

 

5.  The mapping of danger to the country is rooted in a promise to “keep you safe” that of course provokes fears and anxieties of dangers, as much as it responds to an actual cause.  And despite the stay on restraints of immigrations for those arriving from the seven countries whose residents are being denied visas by executive fiat, the drawing of borders under the guise of “extreme vetting,” and placing the dangers of future terrorist attacks on the “Homeland” in seven countries far removed from our shores, as if to give the nation a feeling of protection, even if our nation was never actually challenged by these nations or members of any nation state.

The result has already inspired fear and panic among many stranded overseas, and increase fear at home of alleged future attacks, that can only bolster executive authority in unneeded ways.

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The genealogy of executive prerogatives to defend the borders and bounds of the nation demands to be examined.  Even while insisting on the need for speed, security, and unnamed dangers, the Trump administration continues to accuse the courts of having made an undue “political decision” in ways that ignore constitutional due process by asserting executive prerogative to redraw the map of respecting human rights and mapping the long unmapped terrorist threats to the nation to make them appear concrete.  For while the dangers of terrorist attack were never mapped with any clear precision for the the past fifteen years since the attacks of Tuesday, September 11, 2001, coordinated by members of the Islamic terrorist group al-Qaeda, Trump has misleadingly promised a clear remapping of the dangers that the nation faces, which he insists hat the nation and his supporters were long entitled to have, as if meeting the demand to remap the place of terrorism in an increasingly dangerous world.

The specter of civil rights violations of a ban on Muslims entering the United States had been similarly quite abruptly re-mapped the actual relation of the United States to the world, in ways that evoke the PATRIOT act, by preventing the entry of all non-US residents from these nations.  Much as the PATRIOT act led to the detention of Arab and Muslim suspects, even without evidence, the executive order that Trump issued banned all residents of these seven Muslim-majority nations.  The above map, which was quickly shown on both FOX and CNN alike to describe the regions identified as sites of potential Jihadi danger immediately oriented Americans to the danger of immigrants as if placing the country on a state of yellow alert.   There is some irony hile terrorist networks have rarely been mapped with precision–and are difficult to target even by drone strikes, the executive order goes far beyond the powers granted to immigration authorities to allow the “territoritorial integrity of the United States,” even as the territory of the United States is of course not actually under attack.

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What sort of world do Trump and his close circle of advisors live–or imagine that they live?  “It is about keeping bad people (with bad intentions) out of the country,” Trump tried to clarify on February 1, as the weekend ended.   We’re all too often reminded that it was all about “preventing foreign terrorists from entering the United States,” as Trump insists, oblivious to the bluntness of a blanket targeting of everyone with a visa or citizenship from seven nations of Muslim majority–a blunt criteria indeed–often not associated with specific terrorist threats, and far fewer than Muslim-majority nations worldwide.  Of course, the pressing issue of the need to enact the ban seem to do a psychological jiu jitsu of placing terrorist threats abroad–rooting them in Islamic communities in foreign lands–despite a lack of attention to the radicalization of many citizens in the United States, making their vetting upon entry or reentry into the country difficult–confirmed by the recent conclusion that, in fact, “country of citizenship [alone] is unlikely to be a reliable indicator of potential terrorist activity.”  So what use is the map?

As much as focussing on the “bad apples” among all nations with a predominance of Muslim members–

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–it may reflect the tendency of the Trump administration to rely on crude maps to try to understand and represent complex problems of global crises and events, for a President whose staff seems to be facing quite a steep on-the-job learning curve, adjusting their expectations and vitriol to policy making with some difficulty.  The recent revelation of Trump’s own preference for declarative maps within his daily intelligence briefings–a “single page, with lots of graphics and maps” according to one official familiar with his daily intelligence briefings–not only indicate the possibility that executive order may have indeed developed after consulting maps, but underscore the need to examine the silences that surround its blunt mapping of terrorism.  PDB’s provide distillations of diplomatic, intelligence, and military information, and could include interactive maps or video when President Obama received PDB’s on his iPad, even encouraging differing or dissenting opinions.  They demand disciplined attention as a medium, lest one is distracted by uncorroborated information or raw intelligence—or untrained in discriminating voices from different areas of expertise.

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Filed under Donald Trump, human rights, Immigration Ban, Islamic Ban, refugees