Abigail A. Sewell examines a physician's study of how deprivation shortens lifespan.
The Death Gap: How Inequality Kills
By David Ansell
David Ansell's passionately written The Death Gap presents a powerful case for social inequality as a cause of disease and disparities in health. The social epidemiologist, physician and public-hospital veteran invokes the concept of 'death gaps' to describe differences in life expectancy by race, ethnicity, class and geography.
Ansell uses an approach that is gaining traction in health and medicine, casting health disparities in the United States as arising from the commodification and politicization of health care. He sees the country's health system as another form of structural violence — harm resulting from unjust social systems, such as poor-quality housing and emergency infrastructures. This architecture, anchored by racism, classism and placeism (discrimination on the basis of neighbourhood), fosters ill health in the most marginalized and vulnerable groups, such as poor black people in urban areas and rural working-class white people. For the most unfortunate, such assaults on health status shave away decades of life. As Ansell shows, there is as much as a 35-year difference in life expectancy between the healthiest and richest US neighbourhoods and the most ill and deprived.
The Death Gap lays out general concepts that inform the complex web of structural violence through case studies and synthetic analyses. Ansell invites us into the heart-wrenching story of one of his long-term patients, whose deprived circumstances led to a disability-inducing stroke — a condition rigged, he argues, by the power and dynamics of public policies that cultivate social inequality. Citing the case of a survivor of Haiti's catastrophic 2010 earthquake, he questions the medical practice of recording cause of death according to the illnesses that precipitate decline, rather than the long-term social conditions that place people at risk of risk. And he looks at 'property politics' in relation to race, seeing it as a key mechanism that perpetuates social, political and economic inequality. The same exploitative processes, he argues, affect disadvantaged black people in inner cities, rural white people and reservation-bound indigenous Americans.
Ansell lays the blame for inequality-related damage to health on ideologies that absolve the wealthy of responsibility and motivation for advocating for an equitable society. He also points the finger at how the US health system and some areas of medical research ignore the interplay between life circumstances and health. Income inequality and neighbourhood stressors — such as ambient noise, proximity to highways, exposure to violence and low social cohesion — have an impact, he shows, on biological processes that accelerate ageing and break down the body's ability to fight disease. As the basis for these inferences, Ansell cites the growing body of research that links stress to the length of telomeres — caps on chromosomes whose degeneration is associated with shortened lifespan and age-related illnesses.
He also examines how stringent policing policies such as 'stop and frisk', which arose in the post-civil-rights era to control newly empowered black people, adversely affect mental health and family ties that protect well-being. And he reminds us how inequality deepens the impact of natural disasters such as the 1995 heat wave in Chicago, Illinois, which killed more than 700 people, and the devastation of much of New Orleans, Louisiana, by Hurricane Katrina in 2005. As these cases show, disproportionate numbers of deaths and displacements occur in black communities when public and health-care safety nets fail.
Ansell's road map for achieving health equity is partly based on the successes he perceives as emanating from health-care activism among poor, ethno-racially vulnerable populations in Chicago. For example, after a year of community-instigated demonstrations, hunger strikes and meetings with hospital administrators, the Illinois legislature agreed to more inclusive laws concerning organ transplants for undocumented kidney patients. After the introduction of quality-control measures for breast-cancer screening (pushed by the Metropolitan Chicago Breast Cancer Task Force), the city witnessed a 35% reduction in mortality disparities between black and white women. And local activists were instrumental in highlighting the geographical maldistribution of adult trauma care in Chicago after the shooting of community leader Damian Turner in 2010 on the impoverished South Side.
Turner's case is structural violence in action. He was killed by a stray bullet from a drive-by shooting less than half a kilometre from the University of Chicago Hospital, which had closed its trauma centre owing to budgetary concerns years before. He died after arrival at the nearest trauma centre, 16 kilometres away. Community organizers led sit-ins at the University of Chicago Hospital, prompting academic studies that characterized Chicago as a “trauma care desert”. Finally, the university conceded, establishing such a centre at its hospital for the first time in more than two decades.
At the federal level, the 2010 Affordable Care Act (ACA, known as Obamacare) receives a searing critique. Ansell lambasts its reliance on a tiered insurance system, recommending instead universal 'single-payer' health-insurance systems like those in Canada and Taiwan. But despite ongoing issues with the ACA and its putative replacements, Ansell is optimistic. Citing community responses to the 2008 financial crisis, he shows how neighbourhood unity can act as a buffer against the negative effects of structural violence. In the final chapter, he extols the transformative capacity of his medical peers and the community, and reveals how it is possible to change US health care from a privilege to a right.
The Death Gap presents a Marxian view of inequality as a societal disease that in turn produces biological disease, dispersed differentially across the sociopolitical hierarchy. Although he is a physician, Ansell uses metaphorical language that may stump readers in biomedical fields. Moving beyond epidemiological frameworks that model what would happen to an individual exposed to a single causal factor, Ansell weaves a much more complicated story, in which structures of disadvantage affect every step of the process of survival. The Death Gap provides an overarching framework for understanding the root cause of ethno-racial and economic disparities in illness that seamlessly weaves together the very best research in epidemiology, public health, medical sociology, health policy and psychology.