“Sober but optimistic” is how Dr. David A. Ansell describes the subject of his work on inequities in heath care. Dr. Ansell is the senior vice president of community health equity and associate provost for clinical affairs at the Rush University Medical Center in Chicago, work he says he does as a physician under the umbrella of human rights activist.
He's written two books that call attention to structural violence in healthcare. His latest, “The Death Gap: How Inequality Kills
,” was released this spring. Dr. Ansell spoke Tuesday, June 6, at Western Michigan University Homer Stryker M.D. School of Medicine to talk about the connection between racism and income inequality to health.
There were 260 people in attendance for Dr. Ansell's lecture, according to Tim Ready, Director of the Lewis Walker Institute for the Study of Race and Ethnic Relations, who were co-sponsors of the event. In addition, Dr. Ansell spoke the following day to about 75 MD's at the Grand Rounds of the internal medicine physicians from both hospitals and the medical school.
Ansell went on to meet with about 40 nonprofit and public sector organization leaders at a community leadership luncheon. Ansell's visit came about in part through the efforts of Shared Prosperity Kalamazoo
in the hopes that community leaders would engage with Ansell, especially on the topic of health.
“Structural violence is caused by laws, procedures, practices that disadvantage some over others,” Dr. Ansell says, and he refers to this death gap as a form of structural violence. He says that for every million people who have no health insurance, 1,000 will die every year. When social structures or institutions keep people from being able to meet basic needs such as adequate healthcare it is more than unfair, it is violence
Dr. Ansell began his work as a young resident at Cook County Hospital in Chicago, one of the most famous teaching hospitals in the country. Dr. Ansell called it “run down and decrepit” and adds, “it was allowed to be degraded because the patients it served were poor, Black and Brown.”
Discovering the inequity
Dr. Ansell says everything he learned, he learned at Cook County Hospital. He went there for one reason --“healthcare was a human right.” Dr. Ansell stayed there for 17 years, before moving on to Mt. Sinai Health System, but, before he left, he learned a lot about the troubling practice of "patient dumping."
When a hospital transfers a patient to another hospital after learning a patient is uninsured or doesn't have a means to pay for treatment that is patient dumping. As the publicly funded safety net hospital, Cook County was where patients were "dumped" on a regular basis.
Dr. Ansell saw this going on, and he and a colleague decided to do a study, which he refers to as an “experience in speaking up.” The study tracked 500 patients who were transferred for having no means to pay. It only took three weeks to track that many patients. Uninsured patients weren't told the real reason for their transfer. Instead, they were told the hospital they were being transferred out of didn't have any beds.
Why would the hospitals lie? Dr. Ansell describes it as the insidiousness of structural racism. “How do our systems replicate historical injustices, with white on top and Brown and Black on bottom? Ninety percent of the patients transferred were Black or Brown because they were more likely to be uninsured. Twenty-five percent were unstable at the time of transfer,” he says. “Here I am, a young resident, and who's on the other line? Someone like me. A nice person. They were told by administrators to send patients who were uninsured and I was supposed to accept them.”
The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires hospital emergency departments to stabilize and treat patients, regardless of their insurance status or ability to pay. The law was enacted as a result of Dr. Ansell's and other studies. Dr. Ansell calls EMTALA the only form of guaranteed universal healthcare the United States has. And, he adds, we only have it because people stood up.
U.S. death and the inequality gap
Patient dumping was a symptom of how structural violence disparately affects people's lives. The life expectancy of residents of Chicago's South Side neighborhoods is only 69 years, which is equal to that of such countries as India and the Philippines. But only a few miles away, residents of Chicago's Gold Coast neighborhoods are likely to live to at least 85, equal to the average life expectancy of Singapore and Japan -- the two countries with the longest life expectancies in the world.
That 16-year span is bigger than the difference in life spans between Haiti and the United States and Dr. Ansell notes, this disparity is not unique to Chicago; it is prevalent in communities across the entire United States. “Similar disparities can be seen in Kalamazoo County," Ready says, citing statistics from the federal Centers for Disease Control. "White residents, on average, live five years longer than their African-American neighbors, and the richest 25 percent of area residents live about eight years longer than the poorest 25 percent.” Ready says that these differences reflect "differential exposure to environmental stressors and other social determinants of health related to racism and economic insecurity."
In May, the Washington Post reported
on a study which revealed that while life expectancy, as a whole, is increasing in the U.S., in some U.S. communities life expectancy is declining. And the gap is widening by as much as 20 years.
Locally, Cradle Kalamazoo
, with its focus on infant mortality, is the group most actively working on health equity, Ready says. The YWCA and the Western Michigan University Homer Stryker M.D. School of Medicine have been the lead partners working on this, and Ready says the work that they have been doing is completely consistent with the goals of the Walker Institute.
Healthcare as a human right
Dr. Ansell calls the right to access healthcare, “not a matter of left or right, but a matter of right and wrong.” He says that the right to healthcare is embodied in International Law, Article 25 UN Declaration of Human Rights
and in the World Health Organization's 1946 Constitution
, which the United States signed onto. But, Ansell says, “we've never really taken it to heart.”
A growing majority of Americans believe access to healthcare is a moral issue. According to a Pew Research Center Survey
, 60 percent of Americans believe the government should be responsible for ensuring all Americans have healthcare coverage, while only 38 percent believe it should not be the government's responsibility. That 60 percent is up from 51 percent just a year ago.
Dr. Ansell says that people worry about healthcare and healthcare costs. Deductibles are rising, both with the ACA and employer-based plans, and small businesses, who have to buy their own insurance, struggle to pay healthcare costs.
“People skip care because of this,” he says. “Medicaid is insurance for poor people, older people, and people with disabilities. When you defund Medicaid you defund lots of people. The GOP bill wants to take $600- to $800 billion and give it to the top 1 percent of the country,” he adds.
Dr. Ansell's life work and his books are bringing attention to the statistical inequities in healthcare and fixing the problem will require a shift in the way the U.S. handles healthcare. Dr. Ansell ends his talk with a quote from Louis Pasteur: “One does not ask of one who suffers: What is your country and what is your religion? One merely says: You suffer, that is enough for me.”
Kathi Valeii is a freelance writer, living in Kalamazoo. You can find her at her website, kathivaleii.com.