The Death Gap: How Inequality Kills

by David A. Ansell

We hear plenty about the widening income gap between the rich and the poor in America and about the expanding distance separating the haves and the have-nots. But when detailing the many things that the poor have not, we often overlook the most critical—their health. The poor die sooner. Blacks die sooner. And poor urban blacks die sooner than almost all other Americans. In nearly four decades as a doctor at hospitals serving some of the poorest communities in Chicago, David A. Ansell, MD,  has witnessed firsthand the lives behind these devastating statistics. In The Death Gap , he gives a grim survey of these realities, drawn from observations and stories of his patients.



While the contrasts and disparities among Chicago’s communities are particularly stark, the death gap is truly a nationwide epidemic—as Ansell shows, there is a thirty-five-year difference in life expectancy between the healthiest and wealthiest and the poorest and sickest American neighborhoods. If you are poor, where you live in America can dictate when you die. It doesn’t need to be this way; such divisions are not inevitable. Ansell calls out the social and cultural arguments that have been raised as ways of explaining or excusing these gaps, and he lays bare the structural violence—the racism, economic exploitation, and discrimination—that is really to blame. Inequality is a disease, Ansell argues, and we need to treat and eradicate it as we would any major illness. To do so, he outlines a vision that will provide the foundation for a healthier nation—for all.



Inequality is all around us, and often the distance between high and low life expectancy can be a matter of just a few blocks. But geography need not be destiny, urges  Ansell. In The Death Gap he shows us how we can face this national health crisis head-on and take action against the circumstances that rob people of their dignity and their lives.

Genres: Nonfiction, Medicine, Race, Politics, Health Care, Social Justice, Economics

253 pages, Kindle Edition

Published April 21, 2017

About the author

David A. Ansell (born 1952) is a Chicago-based physician, health activist and author whose efforts at both the national and local levels have advanced concerns about health inequities and the structure of the US health care system.

Reviews

[Susan · Rating 4 out of 5]

Will be assigning this book to my undergrads in a class on health disparities; really interesting book on how where you live is more important than who your parents are (or, as Ansell says, in my favorite line, "a person's ZIP code can be more influential than his or her genetic code") p. 69. This would be especially interesting for Chicago readers as he has spent his time at three Chicago hospitals and discusses Chicago policies/the Chicago area. Highly recommend for anyone interested in understanding why low SES people continue to die early.

[landr · Rating 5 out of 5]

The inequality of the US healthcare system is one of the great tragedies of the modern US. From first hand experience working as a physician and medical leader in Chigago for 3 decades, Ansell recounts the heart rending stories and facts of healthcare disparities and how these arise from the roots of structural racism in our country. I highly recommend this book if are involved in medicine or racial reconciliation. I think this should be required reading for medical students.

[Trisha Mondal · Rating 3 out of 5]

The book is very informative and a good introduction to racial injustice and the role of poverty in medicine. I do think that some sections were oversimplified in terms of the biological basis of how poverty and stress lead to disease. If we know the science, then why not include it? While this book is very well-researched, I'd like some more references throughout. I'm not saying that the arguments in this book are untrue, but that they are not well substantiated. If the purpose is to inform or reinforce, the book is good. But if the purpose is to persuade, I would need much stronger evidence. I appreciate the mention of women and their role supporting the community when it comes to incarceration and reintegration, but I wish the book mentioned more disparities among women. I also thought the solutions at the end of the book were unrealistic and focused too heavily on catering to white Americans. It was presented as a “realistic” solution, but that doesn’t really address the systemic racism that the book aims to dismantle.

[doria · Rating 3 out of 5]

Another medical sociology book. Ansell is a doctor who has first hand accounts of the racial/ethnic disparities in healthcare. His anecdotes and jaw-dropping statistics highlight just how bad it really is - the differences in mortality based on race. He highlights how this comes from structural violence and how, through policy and practice, we need to do better and treat patients for more than just their symptoms and what they can afford - or what the US healthcare system believes they "deserve."

It's not a super interesting/enjoyable/emotionally moving read, but if you're going into the medical field - it really does highlight how deep healthcare disparities go and how structural violence and many historical practices/policies have influenced the devastating statistics and stories we hear today.

He also comes up with some solutions to the problem, but it's definitely a conversation that needs to be happening in policy and medical practice.

[Maggie · Rating 4 out of 5]

med soc book: extremely interesting read ab healthcare disparities, def heartfelt and heavy at times

[Jess · Rating 4 out of 5]

I listened to this as an audiobook. Per usual, I don't like Peter Berkrot as a narrator. Something about his style always feels contrived, but that's beside the point.

Nothing about this book comes as a surprise, though the numerical gaps cited are much larger than I anticipated. I would recommend it to anyone--actually to everyone. Though I worry the people who most need to understand the structural racism that caused the implicit bias the healthcare system, and the United States, operates under won't pick up this book and perhaps won't consider it valid. However, the least that can be done is to try, and I think Doctor Ansell does his best to communicate how issues like redlining, race tax, etc. impacts communities of color both in quality of life and health outcomes.

[Jackson Murray · Rating 2 out of 5]

This book raises an important and urgent issue—the widening gap in health outcomes and life expectancy across socioeconomic groups—but ultimately falls short (in my opinion) in how it explains and addresses the problem.

I have a laundry list of complaints:
- “Structural violence” is too abstract and obscures concrete causal mechanisms at play; many sweeping claims (e.g., that premature death reflects systems “motivated by a desire to oppress”) feel like stretches
- Relies heavily on anecdotes and selective examples, mostly from Chicago; often conflates correlation with causation
- Impulsively attributes outcomes to racism while underweighting economic forces, incentive structures, policy design and tradeoffs, cultural and behavioral factors, etc
- Constantly displays a zero-sum worldview where gains for more privileged groups necessarily come at the intentional expense of the poor
- Often conflates race with class, obscuring broader socioeconomic drivers of inequality; does not adequately explain similar outcomes among poor non-Black populations (e.g., poor whites in Appalachia, Native Americans on reservations)
- Minimizes individual agency and overstates systemic intent; attributes broad blame to large groups (e.g., “privileged” or “white”) for outcomes they did not directly shape
- Many behaviors (e.g., housing choices, investment decisions, hiring decisions, lending practices, consumer preferences, migration patterns) better explained by self-interest and incentives than malice
- Overgeneralizes institutions (healthcare, policing, corporations) as inherently racist or “violent.”; describes police as “enforcers of structural racism” and healthcare workers as “agents of structural violence.”
- Rightly frames mass incarceration as systemic harm (“missing” people), but under-acknowledges personal responsibility; tends to blur distinctions between nonviolent and violent crime
- Not providing healthcare to illegal immigrants is seen as an injustice; I see the real injustice in doing just that, while hard-working citizens are forced to pay for their own coverage without assistance
- Critiques existing systems (e.g., Obamacare) without clearly demonstrating why alternatives (e.g., Medicare for All) would be more workable; claims dubiously that moving from a private to public healthcare system would lessen the administrative load and secure more liberty for Americans (ignoring the would be reality of more bureaucracy and huge tax increases)
- Solutions are somewhat extreme and overly ideological (Marxist) and target politically popular boogeymen: capitalism, globalism, racism, and corporate greed; he underexplores more practical, incremental policy approaches
- Tends to moralize policy debates and play on your emotions; very light on statistics

At the end of the day, I think Ansell and I agree on the problem but disagree on the exact causes, the framing, and the most effective path forward. Disparities in housing, education, healthcare access, and community resources clearly compound over time (and were historically exacerbated by racism) and deserve serious policy attention. I just think it's more reasonable to address these inequalities in a targeted manner (e.g., housing vouchers and zoning reform, school choice, healthcare premium subsidies, childcare subsidies, workforce development programs, and criminal justice reform, to name some) than to rely on sweeping, system-wide explanations and calls to “restructure society.”

Where the book is most compelling is in its call for greater community engagement and a renewed sense of responsibility toward one another—reviving a notion of the common good. It reminds me of Robert Putnam's The Upswing, a book that identifies similar inequities but offers a much more thorough account of their underlying causes. Indeed, when compared with other writers who study poverty, such as Matthew Desmond, Ansell is simply less rigorous (though the book’s brevity partly explains this). More broadly, the analysis would benefit from stronger interdisciplinary grounding, as it often overlooks basic economic and political considerations.

I hate to say it, but maybe activist doctors should stay in their lane and leave development work to economists. Ansell is a microcosm of some of the Left’s ill-fated tendency to make everything about race and identity and to frame ordinary people’s problems in out-of-touch, abstract language.

[Merel van Berge Henegouwen · Rating 3 out of 5]

(3.5) ansell is a passionate and convincing advocate for healthcare inequities caused by structural violence. he draws on a myriad of studies to argue his point that structural violence leads to “death gaps”: the premature deaths of many ethnic and economic minorities due to their ethnicity, economic status, and citizenship status, as well as geographical location. i found ansell’s analysis to be broad and thorough, but at times repetitive and monotonous. as he is arguing for the fact that these are actual human beings, not just statistics, i believe the book would have benefitted to compact these more repetitive parts, and include some ethnographic work and/or otherwise anthropological perspectives for a more whole and integrated analysis. moreover, while ansell does point out these health inequities are due to multiple social, cultural and economic factors, i would have liked to see his solutions to include a more holistic societal approach.

[Kellie · Rating 4 out of 5]

I read this book as part of my medical school's antiracism reading assignment. As someone more familiar with medicine and public health, I felt as if the information, insights, and anecdotes shared in this book were ones I was familiar with. While valuable to see the statistics and studies that support what I've previously learned and observed, some points felt repetitive or blended among chapters.

However, I still wholeheartedly recommend this book to anyone not as familiar with the studies and stories that connect how the complex structures of race, geography, and socioeconomic status (to name a few) affect healthcare outcomes and the differences in life expectancy among groups.

[Isabella · Rating 3 out of 5]

3/5⭐️

[Ietrio · Rating 1 out of 5]

A marxist sermon, emotion sold as science. After all, the author parades an MD next to his name.

[Renu · Rating 5 out of 5]

Disclaimer: I did not read the Kindle Edition but I am far too lazy to change my reading status to reflect that I read the paperback.

A wonderfully written book from Dr.Ansell. Rush Medical College requires all incoming M1's to read this book which not only shows their commitment to equitable health care but also their endorsement of Dr.Ansell's observations of healthy inequality in the US and specifically in Chicago.

I thought this book was very well written because of how Dr.Ansell managed to somehow include a macroscopic view of structural inequality and the intersections of race, poverty, mass incarceration, social justice, structural racism, and past and present segregation while simultaneously staying keyed into his main narrative theme of death gaps due to inequality. Every time I found myself getting further down a rabbit hole of the disproportionate effects of mass incarceration or single payer health insurance and wondering how it all related Dr.Ansell would consistently tie his point back to how inequality is literally robbing Americans of years off their lifespan.

Perhaps what I loved most about this book is how Dr.Ansell doesn't sugercoat his proposed solutions. Too often I see physicians, social activists, and just people who want to see structural change suggest nuanced and clever ways for those at the top to still prioritize profit and power while also somehow turning lives around for people at the bottom. Dr.Ansell does an excellent job laying some truths flat out. Specifically that we cannot continue to idealize, protect, and encourage the relentless pursuit of money and power for the privileged few if we are serious about equity, justice, mercy, and the restoration of dignity for the underserved. It's a simple truth that we often avoid: in order to lift those up who have been systemically oppressed and robbed of money, power, education, access to health we need actively choose to lessen and limit the money and power of those who have amassed (and are amassing) wealth as a product of privilege.

I really admire the way he named these truths and put his readers in between a rock and a hard place and forced us to confront the reality that equity looks like the lesser becoming greater because the greater becomes lesser.

What Michelle Alexander's "The New Jim Crow" and Bryan Stevenson's "Just Mercy" is for lawyers and politicians, Dr.Ansell's "The Death Gap" is to physicians and health care providers. A necessary read for any current or future health care worker who is serious about healthy inequity and the notion that health is a human right not a commodity.

[Patrick · Rating 4 out of 5]

This was an excellent little book, helping me to put health inequities in perspective. Ansell is an MD in Chicago, and he grounds his arguments with examples of what he has seen in Chicago neighborhoods he's worked in. So, this book is especially relevant for Chicago-area residents.

His main thesis is that the disparities in health between nearby neighborhoods in Chicago are due not to racial genetic differences but what the author calls "structural violence".

This is an interesting viewpoint for me because I'm used to thinking of these disparities as the result of environmental factors like pollution. One community might be only a mile from another community and have a dramatic difference in life expectancy. It couldn't all be due to environmental differences because the two communities are so close to each other. The author says many of these disparities are due to differences in quality of care. Although I wouldn't discount environmental sources of these differences entirely, it seems obvious to me now that many of the differences in life expectancies are due to disparities in care.

One of the things the author stresses is that "not having insurance is bad for your health". Some hospitals in wealthier communities pay the bills with insurance. Other hospitals, in poorer neighborhoods, rely on Medicare or Medicaid. The difference is significant. Enough so that care is applied in significantly different ways. And patients without insurance behave differently than patients who have insurance, as well. Most people without insurance only go to the emergency room when they have something terribly wrong going on. They do not receive the preventive care they need to improve their health before it becomes critical.

This book was very interesting to me; it was an easy read, and it helped to inform me on these issues.

[Chuck · Rating 4 out of 5]

A scathing indictment of how our society has created an inequitable health care system. Written by a top physician, in accessible and passionate prose. Fascinating and fury producing.

[Fvandrog · Rating 3 out of 5]

Poor people die earlier than the middle class and the well off, because of a myriad of reasons. Many of those reasons are beyond their fault, or power to change. The author certainly focuses on those; what can society in general do battle health inequality, and in general, poverty.

Ansell describes the poverty in the disadvantaged areas of Chicago, the resulting health issues and reduced life expectancy that causes. Ansell, however, seems to completely ignore the roles and responsibilities of the primary stakeholders, the poor themselves. For sure, part of the blame in making bad choices, whether those are leading to bad health, a bad financial situation or both can be laid at our society as a whole. However, I'd argue that in this book, there is very little evidence that the 'victims' themselves work hard to change their destiny. Certainly, they advocate their 'rights' for good health care and better facilities. But, it seems to stop with pointing out what others should be doing for them.

Overall, whereas this book provides valuable insights with what is wrong the organization of healthcare for the disadvantaged and suggestions for change; it has a definitive bias and is very far from an objective study. Only the disadvantaged and their advocates will take this book seriously, but there is precious little gain in that. It is, unfortunately a missed chance to convince opponents and those undecided about chancing the health care system. A more balanced approach would have served the purpose of the author and those he advocates for much better.

[Rod Pierce · Rating 4 out of 5]

Overall phenomenal book. Only issue is he trashes Obamacare w little acknowledgement of how impossible it was to make ANY change over decades so home run not possible. Conclusion and cure was weak, would have liked more politically palatable, concrete items.
- Ansell is Chicago physician at rush, worked at county and Saini in past each different with respect to SES and racial disparity. Medical education traditionally focused on biological basis for disease, but social, economic & political determinants often bigger.
- SES & race interaction 2/2 practices like redlining in Chicago, prevented blacks from homes & caused white flight. Hyde park life expectancy is 84 - similar to Spain, across Washington park is 68? Similar to Iraq.
- empathy is tough when people into SES and racial enclaves - prevent rich whites from understanding the issues of inner city black communities.
- Beliefs, behavior & biology (3Bs) common justifications for disparities (as opposed to social conditions). Race isn’t surrogate for biology, precision medicine (isodil) is marketing bs, be wary of claims like X background causes Y, background is often social and political constructs w/o genetic data.
- natural disasters tend to expose structural fault lines - heat waves, hurricanes, pandemics. Chicago heat wave in mid 90s killed old, isolated, poor, black people. Katrina - poor blacks “looted” food, while poor whites “found” food.
- Hospitals serving mostly blacks an other minorities have worse outcomes - often hospitals under resourced, do less volume of complex cases (worse procedural outcomes). Sinai in 2012 had about 6M in capital investments, NMH had over 250M - bond rating for NMH is A+ vs Sinai isn’t rated, so no bank will lend to Sinai vs every bank will lend to NMH, modern day red lining!
- Social cohesion and efficacy demonstrate better community outcomes even when equal on SES (Chatham > Roseland). Oak park has city planning neighborhoods have racial integration (as of 2010s). Social cohesion is less present in black neighborhoods.
- Activism. UChicago and trauma center. Result of high rates of wealth erosion after Great Recession → violence south & west sides, killing of Damien turner in 2010, Obama library, opening of ccd, cancer center → call for trauma center. This was almost verbatim rehash of my grand rounds.
- Cure: 1) single payor health 2) activism (opens door for systematic change) 3) shifting institutional culture to pivot toward social determinants of health and disparity.

[Jay A · Rating 3 out of 5]

David Ansell is clearly an able and kind advocate for the issues of healthcare disparity across the Chicagoland area. The relating of statistical data alongside anecdotal evidence is clear and convincing that uneven and unfair care is distributed. Where I take issue is with his solutions which rely on just more government money or higher taxes on wealthier families (under the rubric that they do not pay a “fair share”. Of course, what is fair is never explained or proffered as a reasoned argument. His book details story after story of how institutions (run by individuals or committees) create policies which discriminate. There is also evidence that general health conditions in poor communities for even basic wellness care are missing. But to just through money at a problem without a clear plan is not going to be helpful. The Chicago Housing Authority tried to solve housing issues years ago with the creation of the Robert Taylor Home...and what an unmitigated disaster that was. Partnerships with caring not-for-profit institutions and churches would be a great start rather than just seeking bills from Congress or bills from Springfield where mismanagement and fraud abound in finances.

[Danielle T · Rating 4 out of 5]

A quick read for non-fiction, The Death Gap uses Chicago neighborhoods as case studies for the various ways inequity decreases health outcomes with dramatic life expectancy differences for neighborhoods along the same road. This is structural violence- redlining contributes to placement of facilities in certain neighborhoods, limiting access to care (all while the healthcare system is strangled by labyrinthine health insurance companies). Smaller hospitals might not be able to maintain much needed programs, thus forcing their constituents to travel farther for care (and increase the likelihood of death).

Dr. Ansell also advocates for single-payer healthcare, as current US systems are expensive with control in the hands of insurers for who is in-network, etc.

This book is from 2017, so I imagine healthcare disparities have only widened in the last five years, especially with the coronavirus pandemic exacerbating issues in an already broken system.

[Molly · Rating 4 out of 5]

I’m very glad I read this book. It’s an important reminder of the current horrifying reality of inequality in healthcare in this country, and in Chicago specifically. Dr. Ansell considers both what can be done individually to make healthcare more equitable and what needs to change in the overall system. I want to take this mindset into my own industry as well. I recommend this book to anyone in healthcare or anyone who lives in Chicago, as you will learn a lot about the city and its history. I have a lot of respect for Dr. Ansell and his continued work to get those with privilege to use it to make Chicago’s healthcare system more equitable for all. He shows how we can have a fair healthcare system that provides care for everyone in the city, but we will need to put people ahead of financial gain.

[Viral · Rating 5 out of 5]

This was a really excellently written and approachable book about why the life-expectancy gap between Black and White Chicagoans (and more generally, between Black and White Americans) is so large. Not because of biology, but because of broader social determinants of health - healthcare access, clean air, stable employment and housing, healthy food, and robust social networks. It's been almost a decade since this book was written, and unfortunately all the problems described are still largely the case, the main difference being a shift in at least occasionally acknowledging the existence of social determinants of health in some healthcare educational contexts. Still, a powerful text that should continue to be assigned to young healthcare professionals until it is made obsolete by the elimination of systemic racist segregation in our society.

[Andrew Mohama · Rating 4 out of 5]

Excellent history and context of death gaps, particularly in the Chicagoland area. Wakes you up to the harsh reality of redlining, effects of racism (both historically and still today), and inequitable public health and housing policies that continually lower life expectancy of BIPOC. I learned a lot about public health and SDOH, and it made me both fascinated and deeply frustrated. A bit redundant at times, but the stories stick with you and Dr. Ansell has enough experience to stand strong behind each story and claim.

This was assigned reading for medical school at Rush, and I’m impressed with the anti-racism curriculum. Spurred some important conversations and provided context for training in medicine in Chicago

[Duane · Rating 5 out of 5]

Makes the case that what he calls structural violence leads to shortened live & lagging health outcomes in US Black & Brown communities. It's not biology & behavior but planned segregated neighborhoods, concentrated poverty, lack of jobs & resources in communities of Color. mass incarceration, abysmal heath care availability & infrastructure & lack of political power. The result is living on one side of a street or railroad track can determine if your your life expectancy is 60 or 85, which he calls the death gap. He asserts that beginning with developing empathy can push us on the road to making the structural changes to make health care in the US a right, not an option, like all other industrialized nations.& creating the insti

[Kelly · Rating 3 out of 5]

Very interesting book that has definitely changed my mind on healthcare. I docked a couple points because most of the data is anecdotal stories, and really only focuses on Chicago...which makes sense given the author's experience as a primary care physician there. Would love to see a more thorough look at these issues, including more detailed proposed solutions than this book has. The author mainly advocates for a single payer healthcare system as a panacea, but does not bring up ways that could also contribute to inequality in access, nor other fundamental flaws. Again, I get it...the scope of this book is limited. Very interesting read at the least.

[Carie Gall · Rating 4 out of 5]

A telling account of the multiple factors that impact people's life span including systemic discrimination and racism. This goes well beyond health care and includes the justice system, real estate agents and employment. However the health care system is a contributing factor with faulty research indicating that there are biological differences between races which is untrue, inequitable distribution of health care resources and policies which discriminate. This accompanied by the racism that people use within their professional practice where different treatments are recommended based on race.

[Ally Robinson · Rating 5 out of 5]

I don’t normally write reviews, but I absolutely loved this book! I started reading about the racial divide in this country while working with homeless youth in Seattle. I’ve read dozens of books at this point on how poverty and race are intertwined and so far this is my favorite one. My entire family since migrating to this country has been based in Chicago, until my generation that is. Both my parents were born and raised in Cook County so it was a great way to get my parents interested in this book and to bridge a gap so to speak. Fantastic book! I’d highly recommend it.

[Becca · Rating 5 out of 5]

This book was eye opening even for myself who grew up on the Chicago area and now is a healthcare provider at Rush, I learned so much about my hospital and those in the Chicagoland area that I was unaware of. I’m so happy Dr. Ansell and his team took the time to research and document this incredibly important information. It is both disheartening and inspiring. I’m left with a passion to care for all patients holistically not just the medical problem in front of me but what systemically led them to this point.

[Brigid Hughes · Rating 5 out of 5]

Every future physician should read this. I love learning about justice issues but have rarely found a book that goes into depth about the very issues of healthcare and systemic inequality that I am so passionate about. This book was enlightening for me about some of the barriers within medicine and how physicians can overcome them. It also made me intrigued about the possibility of working as he is as a physician to educate others about the broken systems and begin to work towards fixing them. I will definitely reas again!!!

[Journey Amundson · Rating 3 out of 5]

Dr. Ansell shares his personal experiences with systemic racism as a physician in Chicago. He is a voice for the voiceless and backs up all of his claims with personal stories and TONS of data. It was a really easy read, although many of the chapters felt random. the connection was systemic racism and how it leads to a death gap, but also tackles many other points which I enjoyed but it felt a bit random. I wish it gave more advice on what to do or how to talk to others who don't understand systemic racism

[Morgan · Rating 5 out of 5]

A really interesting read about how health inequality persists in America and contributes to stark differences in mortality rates across communities. I’ve never read a book from the medical section of the library before, but this book was written in a really accessible way that intertwined research with the author’s own experiences as a doctor in Chicago. Quite depressing but fascinating enough that I couldn’t put it down, and the lessons in this book surely carry even more weight in the wake of COVID-19.

[BumSu Park · Rating 1 out of 5]

Please read with grain of salt since I could not finish this book for it was too garish and too much appeal to empathy.

I started reading this thinking it will be very statistics based. While all the sources are cited, the statistical figures and significance are not at all conveyed in his writing. He would do himself better justice if he appealed to the stories that the statistics could tell than his constant reference to Windora or other anecdotal cases that did not do much but appeal to readers’ emotions.