The Death Gap: How Inequality Kills

“We all die. But tens of thousands of Americans die too early. These early deaths are not random events. These deaths strike particular individuals who live in particular American neighborhoods.”

Ansell starts the Preface with these sentences. Ansell uses a universal truth for the sentence “We all die” juxtaposed to the specific situation expressed in the sentence “But tens of thousands of Americans die too early.” This juxtaposition emphasizes the specificity of the situation in the case of the Americans affected by poverty. The repetition of the word “particular” in “particular individuals” and “particular American neighborhoods” emphasizes the targeted nature of these deaths, suggesting a non-random pattern influenced by socio-economic and geographical factors.

“In my three-plus decades as a doctor who practiced along Ogden Avenue, I learned a simple truth. Where you live dictates when you die. This is not just true in Chicago. Every region in the United States has a street or highway like Ogden Avenue. Travel Third Avenue in New York thirty blocks from the Upper East Side to Harlem, and lose ten years of life. Take a short cruise along the 405 in Los Angeles, and sixteen years of life expectancy vanish.”

Ansell’s assertion that “Where you live dictates when you die” highlights the deterministic role of one’s living environment on health outcomes. By referencing specific streets and highways in various major cities, Ansell uses metonymy to represent broader socio-economic disparities, making the abstract concept of health inequity tangible through concrete examples.

“We speak of America as a democracy, 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. Because of their influence, the United States is vastly more unequal than other advanced industrial societies. And as inequality has increased, there has been a corresponding impact on life expectancy. Because life expectancies are so low in so many neighborhoods, the United States as a whole has dropped to the bottom of the world’s developed countries in life expectancy.”

Ansell contrasts the ideal of democracy and the reality of plutocracy in America. The term “plutocracy” is used to describe the disproportionate power held by the wealthy, a small minority, who are depicted as having control over life and death decisions—a hyperbolic statement that emphasizes their significant influence on societal conditions. Ansell criticizes systemic issues and calls for introspection on the societal structures that perpetuate inequality, alluding to the debate surrounding Healthcare as a Human Right VS Commodity that he will explore later on.

“This kind of violence is called structural violence, because it is embedded in the very laws, policies, and rules that govern day-to-day life. It is the cumulative impact of laws and social and economic policies and practices that render some Americans less able to access resources and opportunities than others. This inequity of advantage is not a result of the individual’s personal abilities but is built into the systems that govern society. Often it is a product of racism, gender, and income inequality.”

Ansell uses the term “structural violence” to encapsulate the pervasive nature of inequality embedded within societal frameworks, stressing the Environmental and Social Determinants of Health Disparities. He emphasizes how systemic issues, rather than individual failings, create significant disparities in access to resources and opportunities. Ansell also argues that health outcomes are direct manifestations of deeper societal inequalities, such as racism, gender, and income disparity.

“[T]here are large gaps or inequalities in death rates. These gaps have been broadly called health inequities. When these gaps are the result of the health care system, they are called health care inequities. I prefer to use the term death gaps because it describes the actual outcomes of health inequity. People die prematurely because of inequity—that is, they experience higher death rates than would be expected in the absence of this inequity. A society where all people experienced the same mortality independent of race, gender, socioeconomic status, or geography would have no death gaps.”

The phrase “death gaps,” used also as the name of the book, conveys the severe consequences of health inequities, emphasizing the tangible, life-and-death outcomes of systemic issues. By framing these disparities as “gaps” and specifying their causes—such as the health care system—Ansell highlights the structural nature of the problem and challenges the reader to envision a society free from these inequities, invoking Healthcare as a Human Right VS Commodity.

“There is an old tale about a country doctor. A man comes to his office with a broken leg. As the doctor repairs it he asks, ‘How did this happen?’ The man replies, ‘I fell in a hole in the road.’ The next day, another man shows up at the doctor’s office with a broken leg. Sure enough, as the doctor repairs the limb he discovers that this man had fallen into the same hole. The next day a third man comes to the office. He too has a broken leg; he had fallen into the hole as well. The next day the doctor grabs a shovel, leaves his office, and fills up the hole in the road.”

Ansell uses a parable to illustrate the concept of addressing root causes rather than merely treating symptoms. The repeated encounters with patients who all suffer from the same injury due to the same hazard, symbolized by the hole in the road, serves as an allegory for systemic issues that persistently harm individuals in society. The doctor’s ultimate decision to fill the hole symbolizes proactive intervention and preventive measures. Ansell’s effort in The Death Gap is to inspire this type of action in different medics and in society at large, invoking The Role of Community Activism.

“We think about racial segregation as a phenomenon of black neighborhoods, when it is in fact an issue of white neighborhood organization. In parallel to black neighborhood segregation, almost 90 percent of suburban whites live in communities that are less than 1 percent black. Many of these neighborhoods became segregated enclaves of concentrated advantage, unwilling to recognize that their advantages came at the expenses of others, to the detriment of the common good.”

The quote challenges the conventional perception of racial segregation by shifting the focus from Black neighborhoods to the deliberate structuring of white neighborhoods, underscoring systemic racial organization. It highlights the pervasive segregation in suburban white communities, which maintain significant racial homogeneity and concentrated socio-economic advantages, often at the expense of marginalized groups.

“Black America lags thirty places behind the United States as a whole on the Human Development Index, which measures things like health, life expectancy, education, and income. The imprisonment rate of black Americans is the highest in the world, and the homicide rate resembles that of Haiti. On the Fund for Peace’s Fragile State Index, Black America would be on the ‘High Alert’ list. If Black America were a country, we would have to send in foreign aid. This disastrous scenario could not exist if structural violence did not sustain it.”

Ansell employs comparison and hypothetical situations to emphasize the severe socio-economic disparities faced by Black Americans. The analogy of Black America as a separate country on the Human Development Index and Fragile State Index uses hyperbole to illustrate the extent of systemic inequality and marginalization. Ansell wishes to emphasize that poverty crises in the US are much more pervasive that the average affluent US citizen may realize.

“Harvard sociologist Robert Sampson is a broken windows skeptic. He asked: what if it is not disorder itself but the perception of disorder that tarnishes a neighborhood’s reputation? Walk down the south side of the Seine in Paris, and long stretches of the embankments are decorated with vast expanses of multicolored graffiti. However, against this background, couples stroll hand in hand in the twilight hours along the river. Why is this graffiti perceived as ‘colorful’ or ‘edgy’ while graffiti in North Lawndale or inner-city Houston evokes crime, fear, and urban decline?”

Ansell uses contrasting imagery and rhetorical questions to challenge the broken windows theory by highlighting the subjective nature of perceiving disorder. The comparison between the graffiti on the Seine in Paris, seen as “colorful” or “edgy,” and similar graffiti in impoverished areas in the US, usually associated with crime and decline, emphasizes how societal biases and contexts shape perceptions of neighborhoods. By citing the skeptical perspective of Robert Sampson, Ansell suggests that, rather than the actual presence of disorder, it is the perceptions themselves that contribute to a neighborhood’s reputation.

“Contrary to the broken windows theory, real disorder did not predict neighborhood decline. However, race-and poverty-conditioned perceptions of disorder in a neighborhood were powerful and durable predictors of future neighborhood decline. When such racial perceptions are widely shared across social networks, they become ‘sticky’—that is, they become even more predictive of a neighborhood’s downward dive, especially if it is nonwhite. If it is widely perceived that a neighborhood is bad, it will become bad.”

Further debunking the broken windows theory, Ansell emphasizes that actual disorder is not a predictor of neighborhood decline. Instead, Ansell argues that ingrained prejudices do more harm than the disorder itself. The term “sticky” describes how shared perceptions solidify and perpetuate negative outcomes, particularly in non-white neighborhoods. Central to Ansell’s claim is the idea that that the social construction of a neighborhood’s reputation significantly influences its trajectory.

“Disbelief and skepticism are the usual responses when I raise the issue of structural violence and the death gap. People immediately jump to the three Bs—beliefs, behaviors, and biology—as the reasons for the health and life expectancy differences. And you cannot blame them. After all, not a day goes by that the news doesn’t blast a story about diet or exercise: how eating nuts or brisk walking can lengthen one’s life; how the poor are lazy and don’t take care of themselves. My dinner mate’s assertion that individual lifestyle beliefs and bad habits drive health outcomes is difficult to refute.

But it is incorrect.”

In this quote, Ansell recounts his own experience with the simplistic explanations that individuals from wealthy backgrounds use for explaining health differences, which he critiques as superficial and misleading. By juxtaposing the pervasive media narratives about diet and exercise with the reality of structural violence and the Environmental and Social Determinants of Health Disparities, Ansell highlights the fallacy in attributing health outcomes solely to individual choices, arguing that these mainstream explanations are incorrect and overlook deeper systemic issues.

“To think about race as a political classification requires us to redirect our causal explanations for racial inequities from the biological to the political structures of governance and social control that drive the inequities. This requires a shift of perspective about diseases and their treatments […] [I]f we believe that racism and poverty cause diseases and premature mortality, then the solutions have to be directed at the economic systems and political structures that are perpetuating them.”

This quote from Chapter 5 urges a shift from biological to political explanations. By linking racism and poverty to diseases and premature mortality, Ansell underscores the importance of addressing the underlying socio-economic and political systems to achieve meaningful health equity, thus calling for a comprehensive re-evaluation of how society tackles health disparities.

“The scientific research on the biological effects of concentrated poverty and disadvantage is recent and compelling. A growing set of discoveries suggests that exposure to chronic environmental stress causes biological changes within the body that predispose individuals to develop premature disease. High ambient and psychosocial stress activates the neuroendocrine system in the body, the ‘fight or flight’ mechanism […] Then in a cascade of events, the ‘stress hormone’ cortisol and other activated inflammatory promoting factors are released from cells.”

Ansell employs scientific terminology to articulate the physiological impacts of chronic environmental stress, using recent scientific research to substantiate his claims. Thus, he illustrates the biological mechanisms that link concentrated poverty and disadvantage to premature disease. The use of terms like “ambient and psychosocial stress” and “inflammatory promoting factors” support the connection that Ansell establishes between environmental stressors and biological responses. Ultimately, the author aims to emphasize how socio-economic conditions can precipitate adverse health outcomes through a cascade of physiological events.

“The Chicago heat wave of 1995 and the aftermath of Hurricane Katrina in New Orleans in 2005 were environmental disasters that exposed structural flaws in American society […] In both cities, the most fragile neighborhoods had been in disaster states for years: high poverty, limited mobility, substandard housing, high illness and mortality rates. Social networks had been frayed by mass imprisonment and joblessness. In both cities, emergency management plans failed to account for the fragility and special needs of the residents of these chronically distressed neighborhoods, and many lives were lost as a result.”

Ansell uses historical examples, such as the Chicago heat wave of 1995 and Hurricane Katrina in 2005, to illustrate how environmental disasters disproportionately affect impoverished and marginalized communities, exposing the real causes of destruction, like poverty, geography, and race. The parallel drawn between the two weather events points to a critical failure in emergency management plans, which neglected the vulnerabilities of distressed neighborhoods, demonstrating the recurring nature of these social injustices.

“Those who evacuated before the storm hit were mostly white and mostly middle class. Those who stayed were mostly black and mostly working class. Those who fled before the storm had privileges that most middle-class Americans take for granted: education, money, reliable access to transportation, social networks that extended farther away from the hurricane-hit area, and access to news reports to warn them of the storm’s severity. Those left behind had none of these advantages.”

Ansell employs the contrast between two groups—middle-class white Americans and working-class Blacks—to highlight the systemic inequalities exposed by a natural disaster. The juxtaposition of those groups, their access to resources, and the results of the weather events underscore the great disparity between those groups. By enumerating the specific advantages that facilitated evacuation, Ansell emphasizes how social and economic inequalities left the predominantly Black, working-class individuals particularly vulnerable. This adds weight to Ansell’s overall argument for the real effects of social disparity on the death gap.

“The rise in black imprisonment rates had no real correlation to the actual crime rates. In fact, while incarceration rates boomed after 1980, crime rates dropped […] Studies show that while there is little to no relationship between the crime rate and the imprisonment rate, or between the crime rate and the proportion of black people in a state, there is a very strong relationship between the incarceration rate and the proportion of black people in a state. In other words, people go to prison in increasing numbers because they are black and poor […] with stunning health consequences.”

Ansell aims to debunk the presumed correlation between rising Black imprisonment rates and crime rates, pointing to a significant disconnect between incarceration trends and actual criminal activity. Asserting that the increase in imprisonment is strongly linked to the proportion of Black people in a state rather than to crime rates, Ansell underscores systemic racial biases and the use of incarceration as a tool of social control and its detrimental impact on the health and wellbeing of Black communities.

“If doctors and nurses are not willing to act on behalf of those who have been marginalized by our society because of social status, insurance status, race, or poverty, who will? […] Just as the police have become society’s enforcers of structural racism in America’s abandoned neighborhoods, administrators, nurses and doctors regularly assume the gatekeeper role to keep the uninsured and the poor from receiving all the care that is available in our institutions.”

This quote uses the rhetorical question to highlight the ethical responsibility of doctors and nurses to advocate for marginalized individuals, emphasizing their potential role as allies against societal inequities and The Role of Community Activism in improving health. By drawing a parallel between health care policies and law enforcement, Ansell underscores the pervasive nature of systemic injustice and urges medical professionals to challenge policies that restrict access to care for the uninsured and poor.

“Institutional racism as a structural cause of increased mortality can sometimes be as banal as a poorly qualified doctor missing a cancer in a poorly run mammography center. In a Chicago study of missed breast cancers, poor women, minority women, and publicly insured women were significantly more likely than well-insured white women to have their cancers missed […] because they are more likely to receive care at substandard facilities, in segregated neighborhoods, than advantaged women are.”

This quote discusses the broader issue of institutional racism in healthcare, pointing to how structural factors contribute to increased mortality among marginalized groups. The phrase “as banal as a poorly qualified doctor” underscore how mundane and routine healthcare failures can have profound and deadly consequences. By emphasizing the disparities in diagnostic accuracy between socially disadvantaged women and well-insured white women, Ansell draws attention to the systemic inequities in healthcare quality and access, demonstrating how segregation and substandard facilities disproportionately affect minority and poor populations.

“This is true for care at clinics as well as hospitals. The doctors who work at clinics that care for predominantly black and other minority populations are less likely to be board certified, have less access to specialty consultation, and work in more chaotic conditions. It is not a matter of the patients’ race or ethnicity. Hospitals and clinics in poor neighborhoods, those that serve uninsured populations or those on Medicaid, often do not have enough resources to provide the very best care. What seems at first blush to be a racial disparity is actually a consequence of structural violence and institutionalized racism. Just follow the money.”

In this quote, Ansell employs a parallel structure to compare the quality of care in clinics and hospitals serving minority populations. The colloquial construction “Just follow the money” underscores the financial roots of institutionalized racism, pointing to the underfunding of healthcare facilities in poor neighborhoods as a key factor in perpetuating the unfair Environmental and Social Determinants of Health Disparities.

“I persist because I have watched too many patients suffer and die because they lacked health insurance or had the wrong insurance card. I persist because I have witnessed the racial and ethnic death gaps enabled by our current health insurance arrangements. I persist because simple fairness dictates that health care is a fundamental human right. I persist because of patients like Windora and Sarai, who deserve better. For those who counter that single payer is too expensive or politically unfeasible, we persist because the American ideal of ‘life and liberty’ cannot be achieved without an equitable and universal health care system.”

In this quote, Ansell employs anaphora with the repeated phrase “I persist” to emphasize his unwavering commitment to healthcare reform. The use of personal anecdotes about patients like Windora and Sarai provides emotional weight and a human face to the systemic issues, illustrating the moral imperative for change in the Healthcare as a Human Right VS Commodity debate.

“Social cohesion and collective efficacy might explain why Chatham’s life expectancy is higher than Roseland’s. Cohesion alone cannot overcome the downward spiral of health that poverty and its associated ills can create in a neighborhood. But social cohesion and collective efficacy might have mitigating impacts on the deleterious health effects of poverty [… ] Nevertheless, the bounceback from the economic decline in the late 2000s was sluggish; the 2007-11 American Community Survey found that 25.2 percent of Chatham households were below the poverty line.”

Ansell uses a comparative analysis between Chatham and Roseland to highlight The Role of Community Activism and collective efficacy in influencing neighborhood health outcomes. The narrative of community response in Chatham illustrates the tangible actions driven by social cohesion. However, the persistence of high poverty rates shows the complexity of socio-economic challenges, which are not resolved by pure will power and collaboration, even when a whole community is involved.

“[A] group of community activists believed that Oak Park could successfully become a racially integrated village. The Fair Housing ordinance created a Community Relations Commission with the mandate of addressing whites’ fears of integration. Once the ordinance was passed, the police chief of Oak Park and other village officials visited white homeowners to convince them to welcome future African American neighbors and to squelch rumors that might fuel white flight. One result, a half- century later, is that 81% percent of Oak Park blocks have at least one black family, there are no segregated apartment buildings, and there are no segregated census tracts.”

Ansell uses historical context and personal narratives to highlight the challenges and successes of racial integration in Oak Park. By detailing the proactive measures taken by community leaders, such as personal visits by the police chief to white homeowners, Ansell illustrates the community’s commitment to integration, which results in a remarkably integrated village in contrast to the hypersegregation of nearby Chicago neighborhoods. This reinforces The Role of Community Activism in his analysis.

“FLY understood the issue as a crisis of morality and health justice, as well as a test of the university’s commitment to the black South Side. The medical center leaders saw it as a question of resource utilization. But it was difficult to frame the debate as simply a resource question in light of the national BlackLivesMatter movement and the depth of racial inequities in Chicago. FLY’s demands extended beyond trauma care. FLY sought a broader program to address the health issue of greatest concern to the community: violence.”

Ansell juxtaposes different perspectives on one central issue, contrasting the view of FLY (Fearless Leading by the Youth) as a moral and health justice crisis with the medical center leaders’ focus on resource utilization. The reference to the national BlackLivesMatter movement and Chicago’s racial inequities introduces a broader social and political context, emphasizing that the debate cannot be reduced to mere resource allocation. By highlighting FLY’s comprehensive demands, which extend beyond trauma care to address community violence, Ansell underscores the organization’s holistic approach to tackling health disparities and advocating for systemic change.