Martin Luther King Jr. Celebration 2019 speaker

Understanding the gap

In 2017, Dr. David A. Ansell published The Death Gap. The book is part memoir and part epidemiological survey, exploring the vast and enduring disparities in the American health care system. Ansell’s subtitle—“How Inequality Kills”—is not subtle. But, the physician and social epidemiologist knows of what he writes, having spent four decades practicing in three Chicago hospitals with diverse missions and uneven resources. That experience taught him a simple truth: Where you live dictates when you die.

To illustrate the point, Ansell cites his own hometown, where he’s mapped life expectancy along the ‘L’ tracks of Chicago’s West Side. Residents of the Loop—the city’s central business district—live to the age of 84. Expectancy dips below 69 years just seven stops down the Blue Line in Garfield Park, a neighborhood of concentrated black poverty. “The last time that life expectancy was under 69 in the United States was 1950,” he told us. “Seven stops, seven decades.”

Ahead of his January 24 lecture at the Health Sciences Campus, we talked with Ansell about his lengthy career, the racial inequities he observed in the medical trenches, and his ideas for national reform.

What pushed you into medicine in the first place?

The story of my life is that my parents were immigrants to the United States. My mother’s family was exterminated in the Holocaust; they were victims of religious persecution, racism, mass incarceration, and genocide. For me, growing up in this country in the 1950s, it was natural to be interested in issues of social justice. That logically led to the Civil Rights Movement, and also led to medicine as a profession, which serves as a foundation for social justice.

I wanted to do good for people. I thought it’d be a way to give back. But pretty early in, I began to understand for the first time how power, resources, and money were distributed in our society, and how that disadvantaged some people—poor people in general and black people in particular. I started to understand that racism and other forms of exclusion were powerful forces that influenced all institutions, including medicine. I couldn’t really articulate it then, but that was really disturbing to me when I discovered it, during my first year of medical school. It led me to consider, for a very brief time, not becoming a doctor and doing something else. Maybe I’d be a forest ranger? Really! I was an outdoorsy guy, and I looked into forestry school. But I walked myself [back] from the edge of the woods when I found other medical students I related to. We all decided to study the U.S. health care system. This was 1974 and 1975. We studied the U.S. health care system and we realized that we wanted to fix it.

You write in the book about working at three very different hospitals—Stroger Jr. Hospital of Cook County, Mount Sinai Hospital, and Rush University Medical Center—all near or on Ogden Avenue in Chicago. How distinct is that experience, in terms of the breadth of patients you were treating and the circumstances from which they came, compared to other people in the medical world? Was that an intentional choice?

Well, I went to the safety net—as someone who was interested in social justice. That led me to Cook County Hospital. The corner of Harrison and Wood streets was everything that was right and wrong about health care in America. On the one hand, we could provide free care to anybody. In all my 17 years at County, even as an attendant, I never billed one patient. We just took care of people; what could be a better way to take care of patients than totally based on need? The first time I ever billed a patient was when I got to Mount Sinai and I was an attending physician. I was the chair of medicine! I was 42 years old before I had to bill a patient. They were glorious years.

But on the other hand, there were things that were out of reach. Patients died. There were things they didn’t have access to. That really struck me. It seared me to the bone.

When I got to Mount Sinai, there you are on the corner of California and Ogden in Lawndale, one of the prototypes for everything that went wrong in America between the 1940s and the 1980s. Black influx, blockbusting, white flight, redlining. When Martin Luther King Jr. was assassinated, people went into the streets in rebellion, and 200 businesses were burned down, and they never returned. But what people don’t talk about is the major industries that left the West Side of Chicago: Maybelline, Kraft, Sears, Brach’s Candy, Western Electric. This left the community bereft of employment opportunities. I didn’t understand that as deeply as I did until I got to Sinai.

Then I moved to Rush. I call that experience “one street, two worlds” in the preface of The Death Gap, because literally within one and a half miles of each other, you had two worlds of neighborhoods, and of health care. Patients at Rush, many of them come from middle class neighborhoods or neighborhoods of affluence. For the others, they almost all came from neighborhoods of concentrated disadvantage and poverty. What really struck me, and I saw it clearly for the first time when I got to Sinai, was how where you lived dictated when you died, well beyond what medicine itself can cure. There was something about the neighborhoods themselves and the exposure to the toxic stress of poverty and racism that actually killed people.

“It wasn’t gun violence and it wasn’t interpersonal violence, either, even though those are problems in those neighborhoods. It was heart disease, cancer, things caused by structural violence that’s built into the rules and regulations that dictate how society works.”
— David A. Ansell, author of The Death Gap

It was violent because people die as a result. It was, to me, palpable and unacceptable. When I got to Rush, it was like I’d landed on a different planet.

Not many medical professionals have these experiences. The doctors who take care of poor patients in America and minority patients are typically different than the ones that take care of white and wealthy patients. They tend not to cross over into these different worlds. I did.

How did you land on the construct of the death gap to explain this inequality?

When I got to Rush, I’d spent almost 30 years in this safety net. Somehow, I landed in this beautiful place. I felt like I was going into exile. Even though I was chief medical officer and had a lot of work to do, for the first time in my career, I had a chance to reflect. That was really critical for me.

The other thing that was really clear to me when I got to Rush was that it felt hermetically sealed off from the experience of the West Side neighborhoods. It was as if everything that was visible and visceral for me was largely invisible. That really stimulated me to think, how do I tell this story?

I’d give talks and I’d put two little baby faces up on a screen. The white baby born in the Loop would live to be 84. The black baby born in Garfield Park would live to be 69. How is it that these two babies, born with the same potential, will have different life courses simply because they live six miles away from each other? I kept trying to figure out a way to articulate it, to tell a story that people reacted to.

It was when I took the ‘L’ tracks of the West Side and we mapped life expectancy along the ‘L’ tracks. If you lived in the Loop, you lived to the age of 84. As a country, it would rank first in the world. You go seven stops down the Blue Line to the neighborhood of Garfield Park, a neighborhood of concentrated black poverty, and those people live to under 69 years. That’s like Bangladesh. The last time that life expectancy was under 69 in the United States was 1950. Seven stops, seven decades. That really got people’s attention. So, the Death Gap became the new narrative.

Why does this so-called structural violence get second shrift when we talk about health care generally, compared with lifestyle or genetic or biological differences?

I’m going to give you my ideological perspective. People probably don’t realize this, but 2019 is the quadricentennial of the introduction of slavery to the United States. An awful practice. That history was followed by Jim Crow, followed by the scientific racism of eugenics (designed in the United States and perfected by the Nazis), followed by mass incarceration. These structures have been normalized in our society. We’ve normalized the idea that resources and power and money are concentrated largely in certain communities. We use other narratives, and excuses, to make the case for why the eventual outcomes are so bad.

There’s always been a social gradient to health. Anyone exposed to poverty has worse health outcomes. There’s a life expectancy gap based on status in society. In American society, people of color have been assigned the lowest status, just as a caste system would be in India. That assignment is associated with higher mortality for just about every single disease.

There are 171 urban areas in the United States. And in not one of those urban areas is there a white neighborhood that’s worse off than any black neighborhood. In Chicago, there are plenty of poor white people, but there’s not one poor white neighborhood. A child who grows up poor in a middle-class white neighborhood has more opportunity than someone who grows up poor in a black neighborhood.

That’s not to say poverty doesn’t affect white people. It does. But when you look at who is living in poverty, who is more likely to go to jail, who is more likely to go to a hospital that has a one-star rating or an underfunded school—every time, you see black people, black people, black people. You have to ask yourself, maybe there’s something else going on? What is that something else? That’s that invisible hand I call racism and exploitation. I used to call it segregation and disinvestment, but I don’t think those words are the correct words for it.

We’re not comfortable yet as a nation coming to terms with what we’ve done. If you’re white in this world, it’s a little bit like riding up an escalator. If you just walk a little bit faster, you can get to the top. That’s achievement. For black people in this country, in general, they are riding down an escalator. Yes, some of them run up the down escalator and get to the top. But that exceptionalism has been used as evidence to mask a larger problem.

Certainly, behaviors underpin many diseases. But one should ask what underpins these behaviors? And what can we begin to do about it? We know that with people who have educational and wealth achievement, their health is better. And at every level of class, black people have lower life expectancy than white people. It’s likely due to the impact of racism itself.

If you reframe inequality as an epidemic, as you argue for in the book, what are the most efficient ways to stanch that epidemic?

I like to say there’s inequality and there are inequities. There are both, because of the way we’ve designed our society. We have massive racial segregation. We have unequal access to goods and resources simply by geography and by the distribution of resources in those geographies. The solution has to be some redistribution of wealth. We need a reparative solution. The Affordable Care Act is a great example of wealth redistribution. The tax bill of 2017 was another example, but in the other direction. Part of the reason why people live longer if they’re poor in San Francisco or New York City than in Detroit or Birmingham is because of public policies. People have better access to schools, to education, to health care, to better paying jobs that lead to better health. It’s really economic and educational.

The other thing we know is that in an unfair society, everyone fares worse. Even for people with a higher life expectancy, it isn’t as high as it could be if we had a fair society.

So, it’s wealth creation. It’s redistribution of resources into these neighborhoods. It’s jobs. We wouldn’t eliminate it all completely, but it would make a big difference.

Learn more about the theme of this year’s MLK celebration, Addressing Disparity through Awareness, Advocacy, and Action, and other events and activities at Loyola starting January 21.

“You have to ask yourself, maybe there’s something else going on? What is that something else? That’s that invisible hand I call racism and exploitation. I used to call it segregation and disinvestment, but I don’t think those words are the correct words for it.”Dr. Ansell