Book Review: The Death Gap by David A. Ansell

Review by Susan Zinner.

In less than 200 pages, Dr. Ansell, an internist who has worked at three Chicago hospitals that serve a high percentage of people from marginalized communities, explains why where you live has a bigger impact on your health than who your parents are. Or, as he writes, “a person’s zip code can be more influential than his or her genetic code” (69).  To illustrate this point, he explains that driving east on Ogden Avenue in Chicago from the manicured neighborhoods of the wealthy western suburbs into the poor inner city area, a distance of only 30 minutes or so, reveals a dramatic difference in life expectancy of nearly two decades (viii).

31939365In The Death Gap: How Inequality Kills, Ansell addresses the role of complex structural policies and laws, such as redlining, which systematically excluded minorities from living in middle-class, majority-white neighborhoods with better public schools, hospitals, and grocery stores; prison policies created to target African-Americans in the 1980s despite declining national crime rates;  and the lack of social cohesion in many poor communities.  He considers the historical roots of the infamous U.S. Public Health Service Tuskegee syphilis study where hundreds of poor African-American men received no treatment for their illness in the mistaken belief that race impacted the expression of this STD and its lasting impact on healthcare today.  He explains that women of color with breast cancer in Chicago risk having their breast cancer misdiagnosed at much greater rates than middle, upper-middle, wealthy,  or white women.  Calling upon his four decades of medical experience, Ansell explores the experience of his patients, who have faced personal challenges while struggling with diabetes, heart disease and other conditions. 

The author cites not only individual cases of inequity, but structural inequities as well.  He explains how the Chicago heat wave of 1995 and the 2005 Hurricane Katrina serve as examples of systems with structural flaws that were readily apparent beforehand, but had disastrous consequences for the poor.  While the middle-class and wealthy were able to escape, the poor were trapped in their respective communities until help arrived.  He also notes his uninsured patients in Chicago have never received an organ transplant, despite being on waiting lists, but have often served as donors after their deaths.

Early deaths in the African-American community are costly in multiple ways..  When people die young, they do not collect their pensions or Medicare — financial benefits that could help to secure their family’s future — and their communities lose the benefits of their accumulated wisdom.  Furthermore, those of us who are not members of these communities suffer from an unconscionable lack of empathy.  Since middle- and upper-class Americans do not rely on public schools and the need for national health insurance in the way that lower-income communities do, there is political pressure to invest time or energy in these efforts.  Ansell call upon the reader to take the initiative to influence political processes on behalf of the poor.

Ansell argues that the solution to “the death gap” is a willingness to challenge the current systems of structural inequality.  He notes that the University of Chicago was pressured into opening a Level I adult trauma center in 2015 through effective community organizing  and after many deaths, primarily African-American young men.  Only after community groups organized talks with the hospital, after marches by multiple constituency groups and as the result of anger following a number of police shootings of young men, did positive change result.  The author suggests that coalitions of people working together to achieve a common goal, including both those who live in the area and—just as importantly—those who do not but are moved by the plight of the poorest of the poor, may be the agents of change.

By providing an insider’s look at three safety net Chicago hospitals, Ansell is able to narrow his focus to some crucial questions that Americans have traditionally refused to answer about our healthcare system.  He challenges the reader to confront some unpleasant truths.  Anyone interested in improving American healthcare and addressing questions of fairness will find this a fascinating read.

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