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 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.