The Death Gap: How Inequality Kills

The Death Gap: How Inequality Kills

by David A. Ansell, MD

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Product Details

ISBN-13: 9780226428154
Publisher: University of Chicago Press
Publication date: 04/21/2017
Edition description: New Edition
Pages: 240
Sales rank: 359,812
Product dimensions: 6.10(w) x 9.10(h) x 0.60(d)

About the Author

David A. Ansell, MD, is the senior vice president and associate provost for community health equity as well as the Michael E. Kelly Professor of Medicine at Rush University Medical Center in Chicago. He is the author of County: Life, Death, and Politics at Chicago’s Public Hospital.

Read an Excerpt

The Death Gap

How Inequality Kills

By David A. Ansell

The University of Chicago Press

Copyright © 2017 David A. Ansell
All rights reserved.
ISBN: 978-0-226-42829-1



Everyone knows that suffering exists. The question is how to define it. Given that each person's pain has a degree of reality for him or her that others can surely never approach, is widespread agreement on the subject possible? Almost all of us would agree that premature and painful illness, torture and rape constitute extreme suffering. Most would also agree that insidious assaults on dignity such as institutionalized racism and sexism also cause great and unjust injury.


Windora Has a Stroke

The ear-splitting beep of my pager pierced the air. The message was from Megan, the nurse practitioner in my office: "Windora Bradley is in the office. Having a stroke. Stroke team activated. Come ASAP!"

I have been tethered to my beeper since my first day at Cook County Hospital in 1978. I still feel a jolt each time it squawks. My heart pounds. My tongue sticks to the roof of my mouth. Then a hot flush of blood rushes to my temples as an adrenaline release, triggered by the electronic pulse, bombards my nerve endings. My nervous system had long ago hot-wired my "fight or flight" reaction to the pager. It squawks, I react.

I dropped what I was doing and jogged to the stairwell that leads to my office one floor below. It had been many years since I had to run to a medical emergency. My pace was slower and less graceful now but no less determined. Windora was having a brain attack. As I skipped two-by-two down the stairs, thoughts of Windora and her illness flooded my own brain. Her tale had been a long one, though I hadn't thought it was leading us to this. Still, for the last year I had felt like a bystander at a three-alarm fire as I witnessed her body self-combust.

Windora is likely to die young because she is poor, because she is black, and because she lives in the wrong American neighborhood. She is just the latest victim of American roulette, a perverse game where the odds are stacked against the Windoras of the world.

Russian roulette is a deadly game of chance. The gambler places a bullet in the chamber of a six-shooter gun. The chamber is twirled. He places the barrel to his temple, then squeezes the trigger. His fate is determined in an instant.

American roulette is a lethal game that is played out over a lifetime in certain neighborhoods in America. How long you live depends on who you are and where you live. The early deaths that result from American roulette are not up to chance, though. The game is rigged. Live in my neighborhood — a diverse upper middle-class community just beyond Chicago's West Side — and you can on average enjoy a long and healthy life. Live on Windora's block and you will more than likely die an early death. Her medical problems were magnified by her neighborhood and life circumstances, and these are shaped as much by national forces as by local ones.

Since 1975 inequality in income, wealth, and social well-being have risen in the United States as public policies favoring the wealthy have been advanced at the expense of the poor. Tax, economic, and criminal justice polices promoted by Presidents Nixon, Reagan, Bush, Clinton, and Bush II reversed rules in place since early in the twentieth century and redistributed billions of dollars from the middle class and poor to the wealthy. The War on Drugs and draconian sentencing laws led to the highest mass-incarceration rates in the history of the world. Welfare reform, Wall Street deregulation, and global trade laws passed by Congress and signed by President Bill Clinton reversed the social contract between the government and the poor in force since the Great Depression of the 1930s and the War on Poverty in the 1960s. By 2005, the top 1 percent of Americans controlled more American wealth that the bottom 90 percent. One family alone, the Waltons of Walmart fame, is worth $145 billion, equal to the wealth of 43 percent of American families.

The American dream has disappeared for millions of Americans like Windora, who has slipped down the economic ladder over her lifetime. We speak of America as a democracy, but it has become a plutocracy where members of a small minority dictate the shape of life and death in the nation through their grip on wealth. Because of their influence, the United States is vastly more unequal than other advanced industrial societies. And as inequality has increased, there has been a corresponding impact on life expectancy. Because life expectancies are so low in so many neighborhoods, the United States as a whole has dropped to the bottom of the world's developed countries in life expectancy.

A Doctor Meets a Patient

Windora had been my patient for more than thirty years. We met in a small steaming-hot office in the General Medicine Clinic at the County Hospital. She had full cheeks, with a wide ivory-toothed smile, mahogany eyes, and silky ebony skin.

Windora and I were both twenty-seven years old then, and we had both moved to Chicago from elsewhere. But the chasm between us could not have been more stark. I was a white middle-class man from New York State. Windora had moved as a teen from Jim Crow Birmingham, Alabama, to Chicago with her parents and nine siblings. The Bradley family settled into the Cabrini Green high-rise public housing complex on Chicago's North Side and then moved to a house a few miles to the west in the Humboldt Park neighborhood. By the time Windora entered my office, her neighborhood had flipped from a mostly white and middle-class community into an all black and Puerto Rican high-poverty, high- crime one. Meanwhile, I was living in a safe, mostly white and gentrified neighborhood less than three miles away.

Still, we hit it off right away. What struck me the most, even in those early days, was her generosity and easy laugh in spite of her personal setbacks. Over time, as often happens in primary care practices, we became friends. We shared in each other's triumphs and tragedies. She comforted me when my father died, and I was the first person she called when her son had a cardiac arrest. Many of her family members became my patients, including four of her sisters and her son, daughter, and grandchildren. I became an unofficial member of the family.

Windora commanded a kitchen for the Chicago public school system, feeding elementary school kids, for over thirty years. Her salary was barely a living wage, yet she raised two children in her family house. When I met her, she, like so many of my patients, was obese and had just developed diabetes and hypertension. And like so many of my patients, despite working a full-time job and having insurance, she often was forced to decide between feeding and clothing her children and buying her medicine.

Tragedy and stress punctuated her entire life. Her mother and father died in their fifties from complications of diabetes. Her son died of cardiovascular disease at forty-two. Her granddaughter was murdered at the age of eight, one Easter Sunday in the alley near her house. The day before her grandnephew was to start his senior year of high school, he was shot and killed as he pushed a teenage girl out of the line of gunfire.

These events and the passage of time took a devastating toll on Windora's body. Her blood pressure and blood sugars fluctuated wildly despite powerful medications. She developed a blockage in one of the arteries in her leg, giving her knifepoint calf cramps when she walked. Her heart raced out of control in paroxysms of chest-pounding flutters. Her skin mottled. I did what I could to manage her illnesses, but I was unable to slow the relentless course of her maladies. She was a runaway train of symptoms and disease. I was the hapless, helpless conductor.

I was trained on the biomedical model of disease, which holds that diseases arise from biological defects or imbalances in the body. Our medical and surgical therapies are directed at treating these defects. In many cases, these approaches work. Vaccinations have all but eliminated childhood diseases that once killed by the millions. Antibiotics have cured diseases that were once a scourge. Modern therapies for hypertension and atherosclerosis have seen heart-disease mortality plummet. New therapies have prolonged survival for many people with cancer. But despite these miracles of modern medicine, some American communities, like Windora's Humboldt Park, have death rates similar to those in developing countries. Why do these gaps exist?

Structural Violence

It is easy to look at Windora's brain attack through the lens of biology. Her diet, her lifestyle, and her innate biology all led to this moment when her brain is being suffocated by a blood clot in a cerebral artery. But what if it was not just biology that caused her stroke?

There are many different kinds of violence. Some are obvious: punches, attacks, gunshots, explosions. These are the kinds of interpersonal violence that we tend to hear about in the news. Other kinds of violence are intimate and emotional.

But the deadliest and most thoroughgoing kind of violence is woven into the fabric of American society. It exists when some groups have more access to goods, resources, and opportunities than other groups, including health and life itself. This violence delivers specific blows against particular bodies in particular neighborhoods. This unequal advantage and violence is built into the very rules that govern our society. In the absence of this violence, large numbers of Americans would be able to live fuller and longer lives.

This kind of violence is called structural violence, because it is embedded in the very laws, policies, and rules that govern day-to-day life. It is the cumulative impact of laws and social and economic policies and practices that render some Americans less able to access resources and opportunities than others. This inequity of advantage is not a result of the individual's personal abilities but is built into the systems that govern society. Often it is a product of racism, gender, and income inequality. The diseases and premature mortality that Windora and many of my patients experienced were, in the words of Dr. Paul Farmer, "biological reflections of social fault lines." As a result of these fault lines, a disproportional burden of illness, suffering, and premature mortality falls on certain neighborhoods, like Windora's. Structural violence can overwhelm an individual's ability to live a free, unfettered, healthy life.

As I ran to evaluate Windora, I knew that her stroke was caused in part by lifelong exposure to suffering, racism, and economic deprivation. Worse, the poverty of West Humboldt Park that contributed to her illness is directly and inextricably related to the massive concentration of wealth and power in other neighborhoods just miles away in Chicago's Gold Coast and suburbs. That concentration of wealth could not have occurred without laws, policies, and practices that favored some at the expense of others. Those laws, policies, and practices could not have been passed or enforced if access to political and economic power had not been concentrated in the hands of a few. Yet these political and economic structures have become so firmly entrenched (in habits, social relations, economic arrangements, institutional practices, law, and policy) that they have become part of the matrix of American society. The rules that govern day-to-day life were written to benefit a small elite at the expense of people like Windora and her family. These rules and structures are powerful destructive forces. The same structures that render life predictable, secure, comfortable, and pleasant for many destroy the lives of others like Windora through suffering, poverty, ill health, and violence. These structures are neither natural nor neutral.

The results of structural violence can be very specific. In Windora's case, stroke precursors like chronic stress, poverty, and uncontrolled hypertension run rampant in neighborhoods like hers. Windora's illness was caused by neither her cultural traits nor the failure of her will. Her stroke was caused in part by inequity. She is one of the lucky ones, though, because even while structural violence ravages her neighborhood, it also abets the concentration of expensive stroke-intervention services in certain wealthy teaching hospitals like mine.

If I can get to her in time, we can still help her.

Income Inequality and Life Inequality

Of course, Windora is not the only person struggling on account of structural violence. Countless neighborhoods nationwide are suffering from it, and people are dying needlessly young as a result. The magnitude of this excess mortality is mind-boggling. In 2009 my friend Dr. Steve Whitman asked a simple question, "How many extra black people died in Chicago each year, just because they do not have the same health outcomes as white Chicagoans?" When the Chicago Sun-Times got wind of his results, it ran them on the front page in bold white letters on a black background: "HEALTH CARE GAP KILLS 3200 Black Chicagoans and the Gap is Growing." The paper styled the headline to look like the declaration of war that it should have been.

In fact, we did find ourselves at war not long ago, when almost 3,000 Americans were killed. That was September 11, 2001. That tragedy propelled the country to war. Yet when it comes to the premature deaths of urban Americans, no disaster area has been declared. No federal troops have been called up. No acts of Congress have been passed. Yet this disaster is even worse: those 3,200 black people were in Chicago alone, in just one year. Nationwide each year, more than 60,000 black people die prematurely because of inequality.

While blacks suffer the most from this, it is not just an issue of racism, though racism has been a unique and powerful transmitter of violence in America for over four hundred years. Beyond racism, poverty and income inequality perpetuated by exploitative market capitalism are singular agents of transmission of disease and early death. As a result, there is a new and alarming pattern of declining life expectancy among white Americans as well. Deaths from drug overdoses in young white Americans ages 25 to 34 have exploded to levels not seen since the AIDS epidemic. This generation is the first since the Vietnam War era to experience higher death rates than the prior generation. White Americans ages 45 to 54 have experienced skyrocketing premature death rates as well, something not seen in any other developed nation. White men in some Appalachian towns live on average twenty years less than white men a half-day's drive away in the suburbs of Washington, DC. Men in McDowell County, West Virginia, can look forward to a life expectancy only slightly better than that of Haitians.

But those statistics reflect averages, and every death from structural violence is a person. When these illnesses and deaths are occurring one at a time in neighborhoods that society has decided not to care about — neighborhoods populated by poor, black, or brown people — they seem easy to overlook, especially if you are among the fortunate few who are doing incredibly well. The tide of prosperity in America has lifted some boats while others have swamped. Paul Farmer, the physician-anthropologist who founded Partners in Health, an international human rights agency, reflects on the juxtaposition of "unprecedented bounty and untold penury": "It stands to reason that as beneficiaries of growing inequality, we do not like to be reminded of misery of squalor and failure. Our popular culture provides us with no shortage of anesthesia."

That people suffer and die prematurely because of inequality is wrong. It is wrong from an ethical perspective. It is wrong from a fairness perspective. And it is wrong because we have the means to fix it.

Windora's Last Words

I pushed the swinging glass door to my office and hurried into the examination room to find Windora planted on a chair next to Megan. She gaped at me with a dazed, glassy-eyed stare. Sweat beaded and dripped in rivulets down her wrinkled brow.

"Windora, what's wrong?" I asked.

"Ga, ga, ga," she gargled. Something terrible was happening.

"Check her sugar," I said to an assistant. Windora was a diabetic, and low blood sugar might cause something like this.

"Who dropped you off at the hospital?"

She struggled to find her words. "Da, Da, Da, Dr. Ansell," she stuttered.

"Do you mean Darrell?" I asked. Darrell was her longtime companion. She stared at me blankly. There was fear in her gaze.

The medical assistant quickly readied a lancet and stuck Windora's finger, drawing a drop of blood to check her sugar on a hand-held meter.


Excerpted from The Death Gap by David A. Ansell. Copyright © 2017 David A. Ansell. Excerpted by permission of The University of Chicago Press.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents

Preface: One Street, Two Worlds vii

Part 1 American Roulette

Chapter 1 American Roulette 3

Chapter 2 Structural Violence and the Death Gap 14

Chapter 3 Location, Location, Location 26

Chapter 4 Perception Is Reality 42

Chapter 5 The Three Bs: Beliefs, Behavior, Biology 55

Part 2 Trapped by Inequity

Chapter 6 Fire and Rain: Life and Death in Natural Disasters 75

Chapter 7 Mass Incarceration, Premature Death, and Community Health 89

Chapter 8 Immigration Status and Health Inequality: The Case of Transplant 96

Part 3 Health Care Inequality

Chapter 9 The US Health Care System: Separate and Unequal 113

Chapter 10 The Poison Pill: Health Insurance in America 133

Part 4 The Cure

Chapter 11 Community Efficacy and the Death Gap 145

Chapter 12 Community Activism against Structural Violence 160

Chapter 13 Observe, Judge, Act 174

Acknowledgments 192

Notes 195

Index 223

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