The Death Gap: How Inequality Kills

The “disease” of social inequality sends thousands to a premature death

The Death Gap: How Inequality Kills by Dr. David Ansell, 2017.

Health care in America in the 21st century is a living nightmare for millions of American workers. The domination of health care by the giant insurance and pharmaceutical companies, as well as the demands of Wall Street and finance capital for greater profits, ensures that thousands of Americans are sent to an early grave.

The deadly impact of social inequality on health and life expectancy in the US is the subject of The Death Gap: How Inequality Kills by Dr. David Ansell. The book provides a first-hand look by the Chicago doctor into the myriad ways in which growing social inequality results in greater mortality rates for the poorest sections of the working class. The difference in life expectancy between the wealthiest and the poorest in parts of the country can be as much as 35 years—what Ansell terms a “death gap.”

In his book, Ansell seeks to illuminate this disparity of life expectancy in the US and show how it can be fixed. He concludes that “inequality triggers so many causes of premature death that we need to treat inequality as a disease and eradicate it, just as we seek to halt any epidemic.” To the extent that Ansell conscientiously uncovers the social realities confronting wide swaths of the population, he provides a powerful indictment of the health care and social crisis in America.

Ansell is a social epidemiologist, author and physician in Chicago, Illinois. He draws on a wealth of previous experience gained from working 17 years at Cook County Hospital—Chicago’s main public hospital, which treated patients regardless of their ability to pay—where he often saw the worst diseases and injuries associated with poverty. Ansell’s first book, County: Life, Death, and Politics in Chicago’s Public Hospital, was a memoir of his experience at the public hospital and was aimed at exposing the disparities in health care.

Notably, Ansell mentions that he wrote The Death Gap in the spirit of Friedrich Engels and Rudolf Virchow, both of whom wrote about social and health conditions among workers during the revolutionary period of the 1840s in Europe. Virchow, known as the “father of social medicine,” examined how a typhus outbreak in the Silesian region of Prussia was caused by a lack of democracy—thereby showing that a proper response to the epidemic was political, not merely medical. Engels’ seminal work The Condition of the Working Class in England (1844) examined the social origins of the health crisis confronting workers. His work demonstrated that workers in Manchester and Liverpool were dying at far higher rates than their capitalist masters, due to their abject working and living conditions.

In the same spirit, Ansell asks: how do existing policies and laws contribute to the multi-generational poverty and high death rates that exist in various communities in the United States?

Ansell’s book examines how inequality reduces life expectancy in a city like Chicago, where he has worked and confronted these issues for more than four decades. While he examines the disparities of health outcomes in Chicago’s richest and poorest neighborhoods, he also notes that these contrasts are a nationwide phenomenon. He surveys these issues of health inequality in the US through a wide array of lenses—from quality of hospital care for the poorest to housing policies, the effects of incarceration, lack of jobs and more.

In his preface, “One Street, Two Worlds,” he highlights the class divide along just one street in Chicago, Ogden Avenue, where a “twenty-minute commute exposes a near twenty-year life expectancy gap.” Along this street are two different hospitals (Rush University Medical Center and Cook County Hospital) that also highlight the extremes of health care: one a beautiful institution maintained with heavy capital investment and the finest care provided to its higher-income patients; and another, more dilapidated, struggling to provide care to the poorest.

The right insurance card at Rush University Medical Center can provide world-class health care, but a wrong one denies you access to doctors and services. By contrast, the county-run John H. Stroger Hospital provides treatment regardless of ability to pay, but is chronically underfunded, which means that many important services are unavailable and wait times are exorbitantly long. The trauma centers for the poor are so busy people end up dying, thus making their organs available to the rich at other medical centers, where they can benefit from a life-saving transplant procedure. Ansell notes that in his 27 years at Mount Sinai Hospital, on Chicago’s South Side, and at Cook County Hospital, no poor patient ever received such a procedure.

Right nearby both hospitals is Lawndale, a neighborhood with concentrated poverty, whose history, Ansell states, is “the story of rising inequality and premature death in America’s abandoned neighborhoods.” It is a neighborhood which was primarily populated by working class African Americans migrating from the South in search of employment in the middle of the 20th century.

However, following the dismantling of much of the US manufacturing capacity in the 1970s and 1980s as part of the economic changes due to capitalist globalization, large employers like Sears Roebuck and Western Electric fled Lawndale and shuttered their buildings and factories, leaving thousands in the area jobless. The community imploded, with those remaining facing misery and worsening poverty. Incomes plummeted, the number of uninsured grew and life expectancy dropped, leaving a “near twenty-year life expectancy” gap. This is a process seen across the country.

The idea of the “death gap” was formed when Ansell and his friend, Dr. Steve Whitman, observed that 3,200 more African-Americans were dying each year in Chicago as compared to whites. He attributed this to the highly segregated nature of the city, with large numbers of black workers living in much poorer neighborhoods and living in conditions of high-exploitation and extreme social distress. These neighborhoods lack the infrastructure for education, recreation, leisure activities or access to healthy affordable foods, all of which are important contributors to overall health and wellness.

While Ansell at various points states that the “death gap” is due to the “structural violence” and racism of American society—it is clear the themes that emerge over and over in his book are fundamentally issues of class and social inequality. While it is undeniable that racism has played a significant role in the structuring of American capitalist society and in the criminally low life expectancy of working class African Americans, he acknowledges that “the death gaps between high socioeconomic groups and low socioeconomic groups have grown in the past three decades” and that the “rocketing death rate among young white adults and steadily falling death rates among young black adults overall have shrunk the death gap between these two groups.”

Ansell makes important observations about the rise in income, wealth, and social inequality since 1975 that have contributed to the policies that have devastated the poorest layers of the American working class. Specifically, he notes that changes in tax policies, economic deregulation and draconian law-and-order measures by the Clinton administration in the 1990s accelerated the social and health crisis. Life expectancy, he observes, becomes a “barometer” of the impact of the attacks on health care carried out by the political establishment.

Ansell emphatically stresses that the game is rigged against the working class and provides a detailed examination of the nature of social processes that impact individual lives. His analysis affords a valuable insight into the oppression in the daily life of working and poor families through the lens of health care. “We speak of America as a democracy,” he notes, “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.” The unequal wealth distribution has greatly contributed to unequal health distribution, placing the US at the bottom of the world’s developed countries in life expectancy.

Echoing Engels’ concept of “social murder,” Ansell says these inequities are an expression of social and “structural violence” perpetrated by the rich against the working class and poor. According to him, the “deadliest and most thoroughgoing kind of violence is woven into the fabric of American society. It exists when groups have more access to goods, resources, and opportunities than other groups, including health and life itself.” He also examines places like Chicago, New Orleans, Flint, Appalachia, Native American Reservations and the impact of geography and income inequality on mortality.

Throughout the book he highlights various striking facts and analyses on health inequality that bear mentioning. For instance, in a city like Chicago, he notes the primary cause of death is not gun violence, as is often portrayed in the media. Rather, more than half of premature deaths in the city are caused by heart disease and cancer—both of which can be prevented with early detection and other forms of treatment.

Significantly, he also adds that “while blacks suffer” from premature death, “it is not just an issue of racism.” He notes that “poverty and income inequality perpetuated by exploitative market capitalism are singular agents of transmission of disease and early death,” causing an alarming rise of death among white working class Americans. While poor white men and women have a greater chance of living to the age of 65, they too experience significant death gaps relative to their wealthier counterparts. White men in McDowell County, West Virginia—an economically depressed former coal mining region—have only a slightly better life expectancy than poor Haitians, and many in Appalachian towns live on average 20 years less than more affluent white men in Washington, DC.

Ansell stresses that while many in the medical community are trained to examine the “proximate causes” of disease, such as individual high-risk behaviors or biological considerations, he adds there are deeper, more structural and “chronic” causes of health disease—social and economic causes that are measured in decades not days. He notes that the “chain of causation can be long, complicated and incomplete,” with socioeconomic factors left out of many epidemiological studies in the US.

In contrast to such approaches, Ansell explains, “Health inequity is not shaped by a simple relationship between an exposure and a disease but by a series of exposures over a lifetime or, when experienced intra-utero, across generations … the greater the power and resource inequality in society, the more prevalent the disease outcome, the greater the absolute disease burden on those with less power.”

Even one’s DNA is affected by social inequality. Ansell cites one study by Nobel Prize-winning biologist Elizabeth Blackburn on the effects of long-term stress on telomere length. Telomeres are found on the tips of chromosomes in every cell in the body and they protect the cell’s genetic stability by “capping” the ends of chromosomes and preventing degeneration. Poor black women between 49 and 55 are biologically 7.5 years older, with stress and poverty accounting for more than 30 percent of the death gap. Chronic stress caused by social inequality therefore results in shortened telomeres that cause “biological weathering,” premature aging, diseases and early death.

In the final sections of the book, Ansell examines the glaring inequality in health care treatment, and provides a critical assessment of the health insurance debacle known as the Affordable Care Act (ACA), implemented by President Obama and the Democratic Party. Ansell notes that the lack of insurance is the tenth most common cause of death in the United States. Even if a person obtains insurance, it is no guarantee for adequate assessment and treatment. Hospitals that predominantly treat minority and poor patients also have higher mortality rates. These are attributable to the paucity of critical subspecialty services, lack of funding to organize and have provisions in stock, doctors that are less likely to be board certified, and low capital investment for hospitals in poor areas that could reverse chronic shortages and quality of resources.

It is significant that Ansell condemns the Affordable Care Act as a failure, confirming the analysis made by the WSWS from 2010 onwards that it was part of the social counterrevolution against the working class, wiping out gains made by workers in the 20th century. He makes it clear that the ACA is “neither universal nor equitable.” Moreover, he notes that it was from the start a “sweet deal for insurance companies,” a de facto bailout for these giant insurance companies by the government.

Ansell also adds that while premiums are rising at staggering levels—even for those with employer-sponsored health care—wages remain stagnant, pushing families into difficult choices, such as delaying or avoiding medical care for themselves. Part of the ACA also involves the use of Medicaid expansion, but he makes clear that more than one-third of doctors refuse to take Medicaid, and many states have blocked this expansion.

In the concluding chapters, Ansell provides what he deems are his solutions, and this is the weakest element of the book. The doctor’s proposed social cures include various forms of institutional self-reforms of the for-profit health care and hospital systems, pleas for an expansion of “empathy” by the very rich towards the poor, and other forms of political reforms by the ruling class coupled with various types of community activism.

Ansell proposes a single-payer “Medicare for all” system instead of the current for-profit system, stating that health care is a social right. However, even if a single-payer insurance system were to be implemented, it would be woefully inadequate to meet the needs of the working class. As it stands, Medicare has been significantly privatized and eroded with recipients forced to seek out expensive supplemental insurance plans to pay for medical services and prescription drugs.

While Bernie Sanders has cynically proposed such a piece of legislation recently, it has no chance of being passed in a Republican-controlled Congress. Moreover, the insurance and pharmaceutical companies, which bankroll both Democrats and Republicans, fiercely oppose such measures.

Such pleas for reform fall on deaf ears with the decline of US imperialism today and the enormous concentration of wealth in the hands of a financial oligarchy, which accumulates its riches largely through looting society and destroying the social reforms of the past. There can be no solution to the massive crisis of health care facing millions of people today outside of a struggle against the capitalist system. The giant health care and banking institutions must be expropriated and put under the control of the working class, freeing up those resources to meet the urgent health care and social crisis faced by millions today. The fight for a universal health care system, guaranteeing health care as a social right, requires the fight for socialism and a workers government, in opposition to both Democrats and Republicans.

Notwithstanding the limitations in terms of Ansell’s proposed cures, The Death Gap is a significant and important work by a practicing medical doctor who provides a searing portrait of the social and health crisis in the United States. It deserves to be widely read.