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    Author David Ansell Exposes Inequality's Deadly Influence

    David A. Ansell, MD, MPH
    David A. Ansell, MD, MPH

    Drawing on a four-decade career of practicing medicine in Chicago, David A. Ansell, MD, MPH, has written The Death Gap: How Inequality Kills, an indictment of economic inequality and its impact on health. The book was published in May by the University of Chicago Press.

    Ansell is professor of medicine at Rush Medical College, senior vice president for community health equity at Rush University Medical Center, and associate provost at Rush University. He presented on Nov. 6 at Learn Serve Lead 2017: The AAMC Annual Meeting, in Boston, on the topic of academic medicine investing in the community.

    “Ansell’s passionately written The Death Gap presents a powerful case for social inequality as a cause of disease and disparities in health,” wrote a reviewer in Nature. Ansell also published County: Life, Death, and Politics at Chicago’s Public Hospital, a memoir about his time at Cook County Hospiital, now the John H. Stroger Jr. Hospital of Cook County. The Wall Street Journal named County one of the five best health books of 2011.

    AAMCNews interviewed Ansell about The Death Gap and his views on how medical schools and teaching hospitals can—and should—help to eliminate the premature mortality of Americans who live in poverty.

    You write that “structural violence” is responsible for low life expectancy in neighborhoods across America. What do you mean by that?

    An example of structural violence is racism and other forms of exploitation and discrimination that lead to inequality in many aspects of life, including health and life expectancy. Historical injustices are perpetuated into the present, making it difficult for individuals to achieve upward mobility and good health. It is structural because it is embedded in the laws, policies, and routine practices of society (in housing policies, zoning laws, tax laws, banking regulations, etc.) that mire certain neighborhoods in concentrated poverty while at the same time allow other neighborhoods of concentrated affluence to flourish. The premature mortality that ensues is a problem of national scope, affecting folks in inner cities, Native American reservations, and now white people without college education, across the United States.

    Thirty blocks apart in New York City, life expectancy of people in Harlem is 10 years less than those living on the Upper East Side.... Where you live—not just your beliefs, behaviors, and biology—determines when you’ll die if you are low income.

    Today the greatest health crisis isn’t a particular disease, like cancer, diabetes, or heart disease, but hardwired inequality itself. There’s a 35-year difference in life expectancy between the healthiest and wealthiest and the poorest and sickest neighborhoods in America. For example, 30 blocks apart in New York City, life expectancy of people in Harlem is 10 years less than those living on the Upper East Side; in Los Angeles, 16 years of life expectancy vanish along a short stretch of the 405 highway. In the Chicago Loop just two miles from my hospital, life expectancy is 85 years—think Japan. If it was a country, it would be ranked first in the world. Yet, three train stops past Rush [University Medical Center], life expectancy plummets to less than 69—think Iraq.

    Why have you chosen life expectancy as the measure of health?

    Life expectancy is a barometer of the health of a country or a community. It’s the single measure of health that can be used to sum up health status and help us understand health inequality. Life expectancy is a number that takes into account every known cause of death in a population from infant mortality to epidemics to chronic diseases.

    Where you live—not just your beliefs, behaviors, and biology—determines when you’ll die if you are low income. Premature mortality results from the perpetuation of historical, structural injustices, like racism, poverty, and income inequality, into the present. Premature mortality—this death gap—is an American epidemic unlike any other developed country.

    Are you seeing any improvement in health equity in this country?

    While there have been pockets of improvement in life expectancy, overall we are failing. Of note, because of the epidemic of premature mortality among non-college-educated whites and others, the overall life expectancy in the U.S. dropped last year for the first time in decades. We have more high-poverty neighborhoods today than at any time since the 1960s. Since 2000, the number of Americans living in high-poverty ghettos has nearly doubled, from 7.2 million to 13.8 million. Since 2003, the Agency for Healthcare Research and Quality has tracked progress on health care inequity and analyzed more than 250 quality measures. In its 2014 report, it noted [little or] no overall improvement in racial health disparities from earlier years. [Editor’s note: The subsequent 2015 report showed a modest narrowing of disparities in a few areas but not in measures of access or National Quality Strategy priorities.]

    What can academic medicine do to help close the “death gap”?

    Academic medical centers are largely located in areas surrounded by poverty. They’ve always played an honorable role in serving those neighborhoods. But we are anchor institutions—the number one employer in most of those areas—so we have the opportunity to leverage that role. If we want to impact the health inequities in our communities, we have to invest in these neighborhoods.

    There is a new national collaborative, called the Healthcare Anchor Network, that is bringing new focus to the role of health systems in bringing economic vitality to these high-poverty neighborhoods. And we can refocus our population health efforts to address health care inequities within our systems, first by measuring them and then creating the systems to address the care needs of those who need more. That often means taking responsibility for the social and structural determinants of health beyond the medical center walls. Increasingly, these equity discussions are occurring nationally.

    If we care about addressing systemic inequities within and in the neighborhoods outside our institutions, we have to make the achievement of equity a strategic goal.

    Rudolf Virchow [the 19th-century German physician known as the father of social medicine] called doctors the “natural attorneys” for the poor. Academic medicine has to take greater accountability for addressing structural racism and other historical inequities within our institutions. We have not done enough to ensure that voices around the decision-making tables are diverse and inclusive. We need to challenge the leadership barriers, starting with medical school admissions to enroll more black men and Latinos and other historically underrepresented groups. Academic medicine has performed poorly in the retention and promotion of faculty of color to become more representative of the communities we serve.

    How can medical schools and teaching hospitals move the needle forward?

    We all know that traditional health care, as we have taught and practiced it, is not nearly enough to address systemic inequities. Medical centers are large purchasers of services so they can leverage their supply chain, buy locally, create career opportunities within their communities, new businesses in the neighborhood—to mitigate against structural violence that impacts the health of those communities.

    If we care about addressing systemic inequities within and in the neighborhoods outside our institutions, we have to make the achievement of equity a strategic goal. As we move to more value-based care payments and population health, we need to create the kinds of lasting partnerships with members of our communities that bring wellness and economic vitality to their neighborhoods.

    Academic medical centers are training the next generation of physicians, nurses, and other health professionals, and we need to ensure that they are equipped to address the social and structural determinants of health and lead the systematic changes that are needed to achieve health equity and close these unacceptable death gaps. The purpose is not just to point out the gaps but to eliminate them—and academic medical centers are well equipped to take on health inequities—should they choose.